AIDS https://msf-crash.org/en en Controlling an HIV Hotspot. A Realistic Ambition? https://msf-crash.org/en/publications/medicine-and-public-health/controlling-hiv-hotspot-realistic-ambition <div class="field field--name-field-publish-date field--type-datetime field--label-inline clearfix"> <div class="field__label">Date de publication</div> <div class="field__item"><time datetime="2022-11-30T12:00:00Z" class="datetime">30/11/2022</time> </div> </div> <span rel="schema:author" class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/en/user/125" typeof="schema:Person" property="schema:name" datatype="">elba.msf</span></span> <span property="schema:dateCreated" content="2022-11-02T11:53:36+00:00" class="field field--name-created field--type-created field--label-hidden">Wed, 11/02/2022 - 12:53</span> <div class="field field--name-field-tags field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/fr/tags/hiv" property="schema:about" hreflang="fr">HIV</a></div> <div class="field__item"><a href="/en/tags/aids" property="schema:about" hreflang="en">AIDS</a></div> <div class="field__item"><a href="/en/tags/epidemic" property="schema:about" hreflang="en">epidemic</a></div> </div> <details class="field--type-entity-person js-form-wrapper form-wrapper"> <summary role="button" aria-expanded="false" aria-pressed="false">Pierre Mendiharat, Elba Rahmouni &amp; Léon Salumu Luzinga</summary><div class="details-wrapper"> <div class="field--type-entity-person js-form-wrapper form-wrapper field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"> <article data-history-node-id="4202" role="article" about="/en/pierre-mendiharat" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Pierre</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Mendiharat</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Deputy Head of Operations, MSF France</p> </div> <div class="same-author-link"><a href="/en/pierre-mendiharat" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="5258" role="article" about="/en/elba-rahmouni" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2020-06/IMG_0562%20OK.jpg?itok=EI3BSai1" width="180" height="230" alt="Elba Rahmouni" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Elba</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Rahmouni</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><span><span>Since April 2018, Elba has been in charge of dissemination at CRASH. Elba holds a Master's degree in History of Classical Philosophy and a Master's degree in editorial consulting and digital knowledge management. During her studies, she worked on moral philosophy issues and was particularly interested in the practical necessity and the moral, legal and political prohibition of lying in Kant's philosophy.</span></span></p> </div> <div class="same-author-link"><a href="/en/elba-rahmouni" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="11061" role="article" lang="fr" about="/fr/leon-salumu-luzinga" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Léon </div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Salumu Luzinga</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Responsable des programmes à Médecins Sans Frontières, Centre opérationnel de Paris (OCP)</p> </div> <div class="same-author-link"><a href="/en/node/11061" class="button">By the same author</a> </div> </div> </div> </article> </div> </div> </div> </details> <div class="clearfix text-formatted field field--name-field-body field--type-text-long field--label-hidden field__item"><p><em>This article was published on December 22nd, 2021, in the </em><a href="https://www.manchesteropenhive.com/view/journals/jha/3/3/article-p32.xml?body=fulltext" target="_blank">Journal of Humanitarian Affairs</a><em> (Issue 3, Volume 3). A synthesis of this roundtable is available, both in <a href="https://msf-crash.org/en/publications/medicine-and-public-health/about-possibility-controlling-hiv-epidemic-hotspot" target="_blank">English</a> and in <a href="https://msf-crash.org/fr/publications/medecine-et-sante-publique/de-la-possibilite-de-controler-un-foyer-epidemique-de-vih" target="_blank">French</a>. </em></p> <p class="MsoNormal"><em><span lang="EN-US">Despite a concerted international effort in recent decades that has yielded significant progress in the fight against HIV/AIDS, the disease continues to kill large numbers of people, especially in certain regions like rural Ndhiwa district in Homa Bay County, Kenya. Although there is still no definitive cure or vaccine, UNAIDS has set an ambitious goal of ending the epidemic by 2030, specifically via its 90-90-90 (treatment cascade) strategy – namely that 90 per cent of those with HIV will know their status; 90 per cent of those who know their status will be on antiretroviral therapy and 90 per cent of those on antiretroviral therapy will have an undetectable viral load. These bold assumptions were put to the test in a five-year pilot project launched in June 2014 by Médecins Sans Frontières (MSF) and Kenya’s Ministry of Health in Ndhiwa district, where an initial NHIPS 1 study by Epicentre (MSF’s epidemiology centre) in 2012 revealed some of the world’s highest HIV incidence and prevalence, and a poor “treatment cascade”. Six years later a new Epicentre study, NHIPS 2, showed that the 90-90-90 target had been more than met. What explains this ‘success’? And given the still-high incidence, is it truly a success? What follows is an interview on the political, scientific, and operational challenges of the Ndhiwa project with MSF Deputy Director of Operations Pierre Mendiharat and physician Léon Salumu, Head of MSF France Kenya programs, conducted by Elba Rahmouni.</span></em></p> <p class="MsoNormal">&nbsp;</p> <h2 class="MsoNormal"><span lang="EN-US">Introduction: MSF and the Fight against the HIV Epidemic<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: To start, I’d like to broaden the scope of this interview by looking at how Ndhiwa fits into MSF’s long history with AIDS. Almost forty years after the epidemic began, can you retrace MSF’s action in the fight against this catastrophe?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: In the early 1990s there were HIV outbreaks in nearly all the places where MSF was already working. Without any treatments, caring for those patients was impossible and end-of-life support very difficult. Patients were highly stigmatised, even by some in the medical profession. There was an internal debate at the organisation about whether it was pertinent for MSF to do prevention projects; because there was no vaccine, prevention was based solely on behavioural changes like condom use and abstinence.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">In 1996, the advent of triple therapies [combinations of several antiretroviral drugs (ARVs) against AIDS] raised the question of access to treatment for the hardest-hit populations. The vast majority were in the South – particularly in sub-Saharan Africa – and the drugs were in the North. The extremely high price of treatment [$10,000 per patient per year when triple therapy first arrived], the lack of generic versions and the requirement that patients pay part of the costs put triple therapy out of the reach of patients in resource-limited countries. Taking its cues from patient organisations in the North, such as ACT UP, MSF began doing public advocacy to make triple therapies accessible to patients in all countries.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">The first treatment-related actions by MSF members consisted of helping individual colleagues and friends by secretly bringing in drugs that were impossible to find locally. That was also the era of our first HIV programmes, in particular in Thailand and Kenya [in Homa Bay County, where the operation began in 1996], the creation of the Access Campaign</span><span class="annotation"><span lang="EN-US">Access to Essential Medicines Campaign: <a href="https://msfaccess.org/" target="_blank">https://msfaccess.org/</a> (accessed 24 November 2021).</span></span><span lang="EN-US">in 1999, our activism in South Africa alongside patient organisations and the first victories against the pharmaceutical companies, who agreed to go beyond their policy of charging the same price worldwide and adjust their prices to a country’s resources.</span><span class="annotation"><span lang="EN-US"><a href="https://msf-crash.org/en/publications/agir-tout-prix-negociations-humanitaires-lexperience-de-msf/i-stories#south-africa.-msf,-an-african-ngo?" target="_blank">https://msf-crash.org/en/publications/agir-tout-prix-negociations-humanitaires-lexperience-de-msf/i-stories#south-africa.-msf,-an-african-ngo?</a> (accessed 24 November 2021).</span></span><span lang="EN-US">By the early 2000s the price of the treatments had fallen considerably, to about two hundred dollars per patient per year.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">With the arrival of two global actors with multibillion-dollar budgets, namely The Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002 and the United States’ PEPFAR programme </span><span class="annotation"><span lang="EN-US">President’s Emergency Plan for AIDS Relief.</span></span><span lang="EN-US"><o:p></o:p></span><span lang="EN-US">in 2003, the 2000s were a time of worldwide consensus on radically boosting the number of patients on treatment. At MSF, the number of HIV projects supplying drugs to initially small, and then larger, patient cohorts in Africa, Asia and Latin America multiplied. To offset the burden such large cohorts were placing on health systems, we had to find ways to simplify and decentralise care. MSF contributed greatly to the operational research, and that effort brought us a certain fame in the global health world. The PEPFAR and Global Fund programmes were bearing fruit, and by the early 2010s, ARVs were available in most of the world’s countries; the barriers to treatment for people living with HIV lay [and still lie] mostly in local health systems’ weaknesses and a lack of political will.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">For the past decade or so, MSF has had two main objectives. The first is to design projects with a population-based approach in an attempt to impact virus transmission, as was the case with the Ndhiwa project. The second is to improve medical quality, in particular for more difficult-to-care-for patients like children or patients in treatment failure, given that national systems are now capable of managing the simple cases relatively effectively. For the medical teams it’s a question of ensuring successful treatment for all patients – in particular, by measuring viral loads and by taking drug resistance and individual constraints like mobility into account. The number of HIV projects has decreased, and in a sense they have become more specialised.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">In contrast to the 2000s, MSF is now a minor player in the fight against HIV. We are, however, influential with regard to developing innovative strategies and care models such as simplified management. Thanks to our long-standing efforts in the fight against HIV, we have developed some competence in following patients with chronic disease.<o:p></o:p></span></p> <h2 class="MsoNormal"><span lang="EN-US">Controlling an Epidemic Hotspot<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What were MSF’s initial aims in Ndhiwa district?</span><span class="annotation"><span lang="EN-US">Since the decentralisation of governance required by the new constitution (adopted in 2010), Kenya has been made up of 47 counties, themselves divided into districts. Thus, the former Nyanza Province, located in southwestern Kenya on the shores of Lake Victoria, includes Homa Bay County, which itself contains eight districts, of which Ndhiwa is one.</span></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: The Ndhiwa project was designed with the admittedly ambitious aim of reducing HIV incidence in the district using every known biomedical tool – that is, mass testing, early treatment of all positives, better patient care and follow-up and circumcision – to ensure continuity of treatment and sustained viral suppression. It was a medium-term four-year population-based approach;</span><span class="annotation"><span lang="EN-US">A population-based approach aims to improve the health status of a population in a given territory via collaboration among different health actors in that territory.</span></span><span lang="EN-US">it targeted the entire population of Ndhiwa [rather than just a cohort of patients] in the hopes of controlling this health calamity.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: The Ndhiwa project was being devised at a key moment in HIV research. In 2008, the Swiss health authorities claimed – in what would come to be known as the Swiss Statement – that patients who were taking their medications correctly were no longer contagious. That claim, which was especially crucial to serodiscordant couples,</span><span class="annotation"><span lang="EN-US">In a serodiscordant couple one partner is HIV-infected and the other is not.</span></span><span lang="EN-US">was the subject of debates at that year’s IAS [International AIDS Society] conference in Mexico: <em>Has this really been proven?</em> and <em>Can we tell the patients this?</em> Then, in July 2011, the HPTN 052 randomised trial in a cohort of serodiscordant couples showed that early ART (antiretroviral therapy) had resulted in a 96 per cent reduction in transmission to non-infected partners. That confirmation of the Swiss Statement gave rise to the notion that it might be possible to control the HIV epidemic, because the <em>treatment</em> becomes a<em> means of prevention</em>; if everyone with HIV has access to treatment, then transmission will stop.</span><span class="annotation"><span lang="EN-US">Up to that point, prevention programmes had recommended only condom use or abstinence, two behaviours that failed to control the epidemic. In the absence of biomedical tools, public health policies called for behaviour changes; these required a lot of discipline and gave an unreliable result.</span></span><span lang="EN-US"><o:p></o:p></span><span lang="EN-US">In practical terms, that meant urging everyone to get tested, making access to treatment universal, establishing long-term relationships with patients and then watching to see whether the strategy resulted in a lower incidence at the population level. The plan was totally conjectural; although a halt or dramatic reduction in transmission had been shown to occur in a cohort of serodiscordant couples, it had never been proven at the population level.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: How did MSF take up the 90-90-90 strategy?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: MSF fully subscribes to the objectives summarised by the ‘90-90-90’ slogan, which was only ever the quantitative expression of good practices for controlling an epidemic, i.e. giving the greatest possible number of patients access to diagnosis and treatment and then providing high quality care to ensure follow-up and successful treatment. The question then becomes whether those objectives are sufficient. What about the other 10-10-10? Adopting those targets means being satisfied that only 73 per cent of HIV-positive people have an undetectable viral load. UNAIDS now recommends aiming for 95-95-95.</span><span class="annotation"><span lang="EN-US">UNAIDS (2015), ‘Understanding Fast-Track: Accelerating Action to End the Aids Epidemic by 2030’ (Geneva: UNAIDS), <a href="https://tind-customer-undl.s3.amazonaws.com/91c40c40-ad00-4249-88c9-fde9ae71469c?response-content-disposition=attachment%3B%20filename%2A%3DUTF-8%27%27201506_JC2743_Understanding_FastTrack_en.pdf&amp;response-content-type=application%2Fpdf&amp;X-Amz-Algorithm=AWS4-HMAC-SHA256&amp;X-Amz-Expires=86400&amp;X-Amz-Credential=AKIAXL7W7Q3XFWDGQKBB%2F20221102%2Feu-west-1%2Fs3%2Faws4_request&amp;X-Amz-SignedHeaders=host&amp;X-Amz-Date=20221102T133707Z&amp;X-Amz-Signature=8f6bcb0e47436d07a6df540591e9972c2656f87bfbbd8e26a366730d6b62e13a" target="_blank">www.unaids.org/sites/default/files/media_asset</a>/201506_JC2743_Understanding_FastTrack_en.pdf (accessed 24 November 2021).</span></span><span lang="EN-US"><o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">When the Ndhiwa project started in Kenya in 2014 – before the results from Epicentre’s 2018 epidemiological survey <em>Ndhiwa HIV Impact on Population Survey 2</em> (NHIPS 2) became available</span><span class="annotation"><span style="mso-ansi-language:FR">MSF (2020), ‘VIH : l’amélioration de la prise en charge a fait chuter la proportion des personnes infectés dans l’un des foyers les plus touchés au monde’, press release, 24 November, <a href="https://www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus" target="_blank">www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus</a> (accessed 24 November 2021).</span></span><span lang="EN-US">– we weren’t really sure whether the 90-90-90 strategy was realistic, though we had already come close in Chiradzulu, Malawi. I don’t even think most of us believed in it, given the enormous amount of individual and collective discipline the strategy demanded.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: All programmes have targets – otherwise it would be impossible to measure the progress made by organisations or countries more generally. In addition, our organisation frequently adjusts its objectives as new studies come out. While the 90-90-90 targets – which were based on the latest knowledge on the individual and collective benefit of early HIV treatment – were certainly ambitious, they were necessary, insofar as they made it possible to set a course. The targets also made it possible to link individual benefit – i.e. treating people to reduce mortality – to collective benefit – i.e. reducing transmission by identifying patients and starting early treatment in the hopes of controlling the epidemic.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: How did the organisation position itself with regard to the UNAIDS slogan about ending the epidemic by 2030?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: Unlike the 90-90-90 targets, eliminating HIV by 2030 has never been part of our strategy. Generally speaking, that type of objective is very foreign to how MSF works, i.e. having narrowly focused projects and more short-term objectives. ‘Ending AIDS by 2030’ is a slogan that UNAIDS has been using since the 2011 IAS conference in Vienna to re-energise institutional donors, given what was perceived to be ‘donor fatigue’ [decline in donations for fighting the HIV epidemic]. We certainly should have distanced ourselves more sharply from that misleading slogan, because I think anyone who has studied the subject seriously knows that there’s no hope of being finished with HIV by 2030. MSF communications have always evoked the reality of the disease as experienced by the patients, the treatment failures, the day-to-day problems and the still-high mortality, often oversimplifying, without really doing justice to the very significant progress that has also been made.<o:p></o:p></span></p> <h2 class="MsoNormal"><span lang="EN-US">The Ndhiwa Project: Toward a Simplified Model of Care<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What were the major phases of the project?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: During the first two years [2014 and 2015], MSF expended significant resources in the villages in testing and awareness-raising campaigns conducted outside of the health centres, whose capacities we also strengthened. Then, beginning in 2016, we worked to decentralise care and laboratory activity in order to improve access and follow-up [increasing the number of facilities that could test, start treatment and dispense the medications] and to simplify our model to ensure continuity of care, particularly after we left. In 2018, after we had done testing in the entire district, we continued testing at healthcare facilities, reserving home testing for the contacts [family and friends] of those who tested positive in the centres. We also focused on specific categories like children and adolescents, severe cases and patients in treatment failure.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What, in concrete terms, does this idea of developing a simplified care model mean?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: At the Ndhiwa project, like at others, it meant further reducing the number of visits. In countries with weak health systems, you have to lighten the workload for the personnel who are following cohorts with thousands of patients and enable them to focus on visit quality. From the patient’s perspective, less frequent visits can be a significant advantage in terms of time and transportation costs. We offered visits every six months and the option of picking up the medications every three months. That is not so easy to implement because we had to ensure that there was always a stock in health centres and that the patients were able to store their drugs at home. We also set up Community ART Groups (CAGs), a model used at other MSF missions in the southern region; in remote villages, the patients constitute a group. The group members take turns going for an annual visit and bringing back the drugs for the other patients, who don’t have to go anywhere. We’ve been trying to do all that for the past few years as part of the DSDM, or differentiated service delivery model; rather than forcing patients to be followed in a certain way, each person can choose how they would like to be followed. Though it seems obvious, in practice it wasn’t being done systematically. So, even in the HIV sector, which is supposed to be somewhat advanced in terms of considering the patients’ opinion, there is still lots of room for improvement.<o:p></o:p></span></p> <h2 class="MsoNormal"><span lang="EN-US">Partnership with the Ministry of Health<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: This project was conducted in partnership with the Ministry of Health. Why? What did that entail?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: What we had in mind right from the start was to create an activity that was <em>sustainable</em> [because HIV infects patients for life, treatment doesn’t stop until they die] and <em>replicable</em>. By demonstrating that it’s possible to have a population-scale impact on transmission, we were hoping the health authorities would try to do the same thing in other districts. Another major aim of this project was behaviour change, since the entire adult population would have to be screened every year. So we had to act in concert with legal authorities like the Ministry of Health (MoH), and also other leaders like traditional chiefs and local notables.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">While we always say that we work with the ministries of health, we generally prefer to find a place within the health system that allows us to be as autonomous as possible. MSF has historically worked hard to be able to act as independently as possible; while this has been successful, it has also had the disadvantage of making us notorious isolationists who have learned little about working in partnership. MSF staff are unaccustomed to consulting with ministerial authorities before making important decisions; we tend to make our decisions after internal consultation, and then think about how to convince the ministry that it was the right decision. There are many situations, however, where we could benefit by working with others – certainly more than there were 30 years ago, because the capacities of the countries where we work and of other aid actors has increased. Now we’re trying to fight our isolationism. Right from the start, work at the Ndhiwa project aimed to be much more balanced, with technical committees and steering committees within which the MoH, MSF and other HIV actors in the county were supposed to make joint decisions. Yet the first head of mission explained that he had to constantly struggle with his colleagues to make sure that the time frame for decision-making allowed for discussion with the other actors.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: We didn’t have just one collaboration, but two: one with the MoH and the other with the village chiefs and influential figures at the local level. It was essential to ensuring continuity of care after our departure. In order to work with the MoH we had to revise our own standards to adapt to the realities in the field, in particular regarding the number of caregivers, the protocols and compensation. On the other hand, the participation of village chiefs and local figures in developing our activities was an important aspect of their success. They were involved in all phases of the project, especially when it came to setting up testing and awareness-raising activities. That collaboration was a way of asking ourselves, ‘What is essential to the patients with regard to their care?’ One answer, for example, was being able to get medications close to home.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: This project was developed at a time when Kenya was undergoing significant changes in its constitution, with the so-called devolution process giving the regions and their subdivisions greater autonomy. Did that decentralisation process have an impact on how the project was conducted?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: The decentralisation of power also meant decentralisation of our interlocutors. The <em>devolution </em>was a great help to us, because the decision-makers were nearby in the field, and not in the capital. Hence our interlocutors were well acquainted with the reality in the field. However, the central government retained responsibility for defining policies and protocols and for supplying diagnostic tests and drugs. While we often had to deal with coordination problems between the two levels, <em>devolution</em> enabled us to quickly decentralise care by enabling more facilities to test and dispense HIV drugs. It also allowed us to test some simplified care strategies without having to get validation by national authorities.<o:p></o:p></span></p> <h2 class="MsoNormal"><span lang="EN-US">Social Mobilisation<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: The project’s success was predicated on significant behaviour changes on the part of the population. What did you do to bring about those changes, and with what successes and failures?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: The relationship between caregivers and the cared-for is always unbalanced, with the caregivers in a position of superiority. This is true for both psychosocial and patient education visits and for public health messages aimed at the population as a whole. HIV programmes have relied heavily on attempts to change population behaviour, in this case prescribing abstinence [particularly PEPFAR-funded programmes], fewer sexual partners and routine condom use. These rules overwhelmingly continued even after such policies failed. That was particularly true in this part of Kenya, where the anthropological literature had established a link between the HIV epidemic’s explosion and traditional sexual practices in the Luo community. A survey conducted by Dr Xavier Plaisancie</span><span class="annotation"><span lang="EN-US">Xavier Plaisancie’s MD thesis, <em>Representations of HIV and Impact on Care Seeking among the Men of Homa Bay, Kenya</em>, 9 June 2020, <a href="https://msf-crash.org/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa" target="_blank">https://msf-crash.org/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa </a>(accessed 24 November 2021) was the subject of a <em>Cahier du CRASH</em>. That process was the subject of a regular dialogue between Xavier Plaisancie and MSF-CRASH research centre members Jean-Hervé Bradol and Marc Le Pape. The survey described, in particular, the wide range of institutional actors (doctors, politicians, religious leaders, etc.) responsible for the abstinence directive.</span></span><span lang="EN-US">among the male population of Homa Bay showed the contradictions that existed between the social rules regarding normalcy and virility and the public health messages, and the difficulty individuals had in resolving them.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">In Ndhiwa, we immediately made clear our desire not to venture onto this ‘anthropological’ terrain and to focus more on ‘biomedical’ tools: screening, treatment, viral load measurement and circumcision. While that required that patients adopt certain health behaviours, it had little impact on sexual practices and we scrupulously avoided any moralising. We were mindful of the quality of the caregiver-patient relationship both in the design phase of the project and in its implementation, conducting surveys in an attempt to understand how our actions and messages were perceived by patients. I think that strategy contributed to the project’s success, as measured by the very good testing numbers.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: A number of studies have shown the tensions that existed in the caregiver-patient relationship. Caregivers often act like deciders who give orders without explanation, and ask that patients simply obey. In Ndhiwa, village-based activities allowed us to break those habits to some extent. At home visits, the medical team had to start by introducing themselves, and then explain and justify what they were doing. It was the person who welcomed the caregiver; that person had the opportunity and ability to ask whatever questions he or she wanted in order to understand, and the caregiver took the time to answer. The patient could then make an informed choice about refusing or agreeing to the test. In the health centres, in contrast, caregivers spend little time explaining and patients have hardly any opportunity to ask questions. Caregivers tend to assume that if a patient has come in, they consent to the various medical acts – including testing! It’s unfortunate that we did not do enough to improve that aspect at healthcare facilities. Home visits enabled the teams to understand and integrate the importance of real dialogue with patients.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">I had an opportunity to participate in that activity and I was impressed by the teams’ engagement and willingness to listen; their work was appreciated and undoubtedly helped change behaviours in terms of testing, as evidenced by the fact that more than 93 per cent of HIV patients knew their status at the time of the 2018 Epicentre survey, compared to 60 per cent six years earlier.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: There are indeed guidelines and trainings that all stress empathy, listening, respect and being non-judgmental. We can reasonably hope that they will pay off. But the quality of the caregiver-patient relationship is hard to assess. The survey conducted by MFS between 2016 and 2018 among Ndhiwa patients who had gone through periods of treatment failure showed the lack of social and economic support in the programme, though some patients in serious difficulty could have used them.</span><span class="annotation"><span lang="EN-US">Rose Burns <em>et al.</em> (2019), ‘“I saw it as a second chance”: A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya, Malawi and Mozambique’, <em>Global Public Health</em>, 14:8, 1112–24, doi: <a href="https://www.tandfonline.com/doi/full/10.1080/17441692.2018.1561921" target="_blank">10.1080/17441692.2018.1561921</a>.</span></span><span lang="EN-US">It also showed that the conversation and care were not personalised enough. Lastly, there was no robust mechanism for preventing and detecting patient abuse. Nevertheless, the inequality and in some cases violence that characterises the relationship between the medical profession and patients goes beyond the therapeutic relationship, reflecting the inequalities in society as a whole.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What was the impact of mobile testing campaigns in Ndhiwa’s villages?<o:p></o:p></span><span lang="EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: The testing campaigns, both home-based and in the villages, gave us access to hard-to-reach people – primarily men who did not frequent healthcare facilities on a regular basis. Screening ‘outside the walls’ of health centres [by MSF or other actors] accounted for 15–20 per cent of the tests; 80–85 per cent of people were tested at healthcare facilities. While we focused on <em>mobile testing</em> at the start of the project, we later chose to support the healthcare facilities more [compared to the community-based part], to make testing activities sustainable. At the healthcare facilities, we set up a strategy for tracing the contacts of those testing positive. That involved asking the person who tested positive to encourage family members and contacts to come get tested.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: When encouraging people to get tested, it is essential not to underestimate the terrible ordeal that learning their HIV-positive status always is, due to the impact on their emotional, family and sex lives – on top of their fear of illness and death. Nevertheless, we surely benefitted from an underlying change that was occurring: the HIV epidemic had become so widespread in the region that stigmatisation was declining. A quarter of adults there are HIV-positive, and everybody among the three-quarters that are HIV-negative knows, or has known, several HIV-positive people.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: The project also considered expanding access to male circumcision, which several studies say reduces the risk of contracting HIV by 50–60 per cent. Why did you end the circumcision activity?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: We ended that activity because other organisations were taking care of it and getting better results. Culturally, circumcision isn’t readily accepted by Ndhiwa’s Luo community. Unlike us, the other actors were giving cash or clothing to candidates who agreed to be circumcised. We didn’t use that strategy because we couldn’t agree on it internally. The ‘opponents’ argued that paying someone to be circumcised would influence their choice. To me, it was a matter of compensating them for the lost income from the days they couldn’t work after the operation. Aside from that debate, we would have done it if others weren’t doing it or weren’t getting good results.<o:p></o:p></span></p> <h2 class="MsoNormal"><span lang="EN-US">The Results<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: After the first Ndhiwa HIV Impact in Population Survey (NHIPS 1) epidemiological survey, conducted prior to the project’s opening in 2012, Epicentre did a new survey (NHIPS 2) in 2018. A comparison of those two studies was needed to provide follow-up and assess the project. The results showed a markedly improved treatment cascade and a reduction in incidence and prevalence. What conclusions can we draw from this?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: The results were better than we had hoped; according to the NHIPS 2, it wasn’t 90-90-90 that we achieved, but 93-97-95. Fewer than 12 per cent of HIV-positives had a detectable viral load and were potentially contagious. That represents 16,000 people who had access to a treatment that was working, which is a remarkable result.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">It was harder to answer the question about the decline in the incidence of new infections, due to a statistical problem of overlapping confidence intervals. In 2012 there was a 95 per cent probability that the incidence was between 1.1 and 2.5 per cent per year, and in 2018 there was a 95 per cent probability that it was between 0.4 and 1.2 per cent per year. So, there was an extremely low, but not zero, probability that the incidence fell somewhere between 1.1 and 1.2 per cent in both 2012 and 2018. A larger sample would have been needed to ensure the robustness of the comparison. There were, however, other indicators pointing to reduced transmission of the virus. In 2018, 88 per cent of HIV-positives had an undetectable viral load and thus were not contagious, compared to only 40 per cent in 2012; that’s a huge difference. Next, the prevalence among 15- to 24-year-olds fell compared to 2012; that is consistent with low incidence in that age group. So we at MSF were in agreement on the claim that the incidence likely fell in the years prior to 2018, and that we therefore achieved the unheard of and very ambitious goal of markedly reducing virus transmission in a place where the HIV epidemic had been most devastating. I think we can be proud of having contributed to that outcome.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: To what extent can MSF take credit for those good results, given that other actors – the Ministry of Health and EGPAF [Elisabeth Glaser Pediatric AIDS Foundation], in particular – were also working in the district?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: It’s impossible to know how much can be attributed to MSF, since the project was conducted in partnership and in complementarity with the Ministry of Health and the other healthcare actors, themselves funded by institutional donors. The advantage of a partnership lies in the outcomes that can be achieved together. To try to determine MSF’s added value we would have to compare with similar, neighbouring districts or with other actors we weren’t working with, but we don’t have any equivalent, equally detailed, surveys.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What led to those good results?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: There is no magic formula in the fight against HIV. Without a vaccine, we had to use whatever we had – from health centre laboratories to hospitals to village-based actions. That general mobilisation took a lot of resources, sometimes to the detriment of other diseases, but given the prevalence in Homa Bay, I think it was justified.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">And then there are the people behind the projects. The determination and long-term commitment of some key people were crucial to achieving those good outcomes; they had to stay on course despite the inertia inherent to any large organisation, whether MSF or the Ministry of Health. I’m thinking about the heads of mission, the project coordinators, the deputy medical coordinator, the epidemiologists, the desk manager and the Medical Department HIV advisor who supported the project for many years.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: The KENPHIA (Kenya Population-based HIV Impact Assessment) survey is a national survey on HIV done in 2018 by the Kenyan Ministry of Health. How would you interpret the results of that survey?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: The results of the KENPHIA national survey are broken down by region. The only results in Homa Bay County that weren’t as good as the NHIPS 2 results in Ndhiwa [a district within that county] pertained to the percentage of HIV-positives tested. Systematic home testing in Ndhiwa district and the massive mobilisation it both required and generated was key to gaining a few extra percentage points. However, the results were almost the same for the percentage of patients who tested positive and actually started treatment, and for the percentage of those patients who had an undetectable viral load [the second and third ‘90’]. In that regard, the 2015 change in the national protocol in favour of Test &amp; Treat [offering treatment to patients as soon as they test positive] was crucial.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: I’m not surprised that there wasn’t much of a difference between our results and those from the KENPHIA survey. First, they aren’t our results, but the results of a collaboration with the Ministry of Health and the other actors [working throughout the country]. It also proves that more resources aren’t always needed to get better results. We contributed to that success, and I think the most important thing now is being able to sustain it.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: In Ndhiwa district, MSF was willing to take on a very large endemic focus and provide an enormous amount of resources [200 healthcare personnel, free care, etc.] for a small population [the district had 242,726 inhabitants in 2015]. Is this type of project really sustainable and replicable?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Pierre Mendiharat</strong>: As explained earlier, we were hoping from the start to set up a sustainable, replicable activity, and that premise led us to work very closely with the Ministry of Health, and even have university partners [INSERM (French National Institute of Health and Medical Research) and Harvard] do a ‘cost-effectiveness’ analysis of the intervention – with very positive results, fortunately. The cost-effectiveness aspect of the intervention is important, because it suggests that the Kenyan political authorities can economically justify devoting the resources needed to use the approach on a broader scale. The question of institutional capacity and the number of qualified people that that would require still stands, however.<o:p></o:p></span></p> <h2 class="MsoNormal"><span lang="EN-US">MSF’s Departure and the Project as It Now Stands<o:p></o:p></span></h2> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: How did you organise MSF’s departure?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: From the start of the project, our concerns centred on the continuity of our activities; as a result, we based what we were doing on MoH standards. All additional personnel were recruited in accordance with MoH standards and at MoH salaries, to facilitate their retention [50 per cent of the staff were ultimately retained in 2020]. The MSF teams did the mentoring, which consisted of long-term individual support for healthcare personnel. We had about twenty MSF mentors at the start of the project, and then gradually reduced the number and more accurately gauged the MoH teams’ autonomy. We currently have only four mentors, who intervene at the request of MoH staff. It’s a good transition that can go on as long as necessary.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What are your current objectives?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: We currently have two major objectives: to preserve the gains achieved during our six years in Ndhiwa, and to continue to collaborate with the other actors to address any jointly identified gaps or challenges. In practical terms, we are working on initiating third-line treatment in patients who need it.</span><span class="annotation"><span lang="EN-US">Patients who fail the second-line treatment are put under third line following the resistance genotype result.</span></span><span lang="EN-US">These patients are currently waiting six to eight months before switching treatments. We are working together to shorten that wait, and in particular are proposing to speed up the process by facilitating local decision-making without going through a national committee [as is recommended at the central level]. We are also working with the MoH to improve follow-up for adolescents, for whom the treatment failure rate is still about 20 per cent. In the hopes of improving their treatment adherence, we are devising specific management strategies for adolescents: special days and clinics and support that is appropriate to each adolescent’s specific needs.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: Once the Ndhiwa project ends, will the treatment cascade be maintained?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: It’s hard to say. In 2019, I had hopes that that would be the case. Since our involvement was significantly reduced, we have continued to monitor the various indicators, using MoH data, to make sure that the cascade is preserved and to offer support if needed. I was convinced that the Kenyan health system would be able to continue testing, treating and following patients, and retain them, without an outside partner. The KENPHIA survey was very encouraging in that regard. What concerns me now is knowing how to sustain those positive results in the current context of the COVID-19 pandemic and its attendant restrictions.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What have you done in response to the COVID-19 epidemic?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: The COVID-19 pandemic caught everyone by surprise. I think we overreacted by quickly applying overly restrictive measures. In April 2020 we thought, ‘patients with HIV are at high risk and we have to protect them by limiting their contact with healthcare facilities’. To ensure that they continued their treatment, we focused on giving out three-month supplies of drugs. But distributing the drugs was not enough; we should also have kept in contact with the patients and known whether they were taking the drugs – especially the high-risk patients. In many countries, a lot people were in difficulty, and didn’t have food. We should have come up with some innovative strategies that would have allowed patients to continue their treatment <em>and </em>get appropriate social support and follow-up, without being put at risk. We realised that most of our patients didn’t have a phone, so we couldn’t do telephone follow-up. With the patient group system, you only have to contact one person to get access to the others. But that system doesn’t work for every patient [in Uganda, where the practice was developed, only 20 per cent of patients are on that model]. And using community leaders to reach patients isn’t easy either, because some patients don’t want to disclose their illness.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Patients began returning in summer 2020, but we still don’t know whether there were gaps in their treatment. These are things we’ll have to explore in order to determine the impact of the COVID-19 pandemic on our HIV patients.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: How does MSF manage AIDS patients in projects that do not specialise in HIV?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: Although we adopted a resolution in 2008–09, on the medical department’s initiative, to include HIV management at all of our projects, that is currently far from being the case. The teams always find some reason not to do it. Some still don’t think it’s a good idea to start lifelong treatment at a short-term MSF project. I have a hard time understanding this position, because it’s the patient’s decision, not ours. HIV treatments are now available in every country. So we have the option of starting treatment and at the same time support patients by referring them to another facility where they can continue their treatment. And if that’s not possible, we can explain the situation and let the patient decide. In addition, MSF projects that are only supposed to last six months often go on for years. As inconceivable as it may seem, there are still some projects where people being tested for blood donations are not informed that they tested positive for HIV. We should aim for a whole-patient management approach, including HIV management, and use what we’ve learned from HIV to develop ‘simple’ models for chronic disease management and follow-up.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Elba Rahmouni</strong>: What is the current status of the worldwide effort to control the HIV epidemic?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US"><strong>Léon Salumu</strong>: Mobilisation against the HIV epidemic is still strong, and we should keep it up so that previous efforts can be sustained. Now, with the COVID-19 pandemic, we need to remain vigilant, especially when it comes to the countries that the Global Fund considers somewhat higher-income [Kenya, in particular] and, as a result, are supposed to have their funding cut. That change will have to be taken into account so that they are not penalised. That’s an issue we’ll need to keep a close eye on.<o:p></o:p></span></p> </div> <div class="citation-container"> <div class="field--name-field-citation"> <p> <span>To cite this content :</span> <br> Pierre Mendiharat, Elba Rahmouni, Léon Salumu Luzinga, Controlling an HIV Hotspot. A Realistic Ambition? , 30 November 2022, URL : <a href="https://msf-crash.org/en/publications/medicine-and-public-health/controlling-hiv-hotspot-realistic-ambition">https://msf-crash.org/en/publications/medicine-and-public-health/controlling-hiv-hotspot-realistic-ambition</a> </p> </div> </div> <div class="height-computed field field--name-field-related-content field--type-entity-reference field--label-above"> <div class="field__label">Publications associées</div> <div class="field__items"> <div class="field__item"> <article data-history-node-id="3552" role="article" about="/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" class="node node--type-notebook node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2017-05/MSB16331.jpg?itok=Ed8fq3GK" width="450" height="300" alt="Département VIH/sida de l&#039;hôpital régional d&#039;Arua en Ouganda" title="Sida : nouvelle pandémie, nouvelles pratiques médicales et politiques" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Isabel Corthier</div> </article> </div> <a href="/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" class="main-link"></a> </div> <div class="group-content"> <div class="bundle-container"><div class="field--name-field-bundle">Cahier</div></div><span class="field field--name-title field--type-string field--label-hidden"><h3><a href="/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" hreflang="en">AIDS: A new pandemic leading to new medical and political practices</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2011-12-15T12:00:00Z" class="datetime">15/12/2011</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/joan-amondi" hreflang="en">Joan Amondi</a></div> <div class="field__item"><a href="/en/jean-herve-bradol" hreflang="en">Jean-Hervé Bradol</a></div> <div class="field__item"><a href="/en/vanja-kovacic" hreflang="en">Vanja Kovacic</a></div> <div class="field__item"><a href="/en/elisabeth-szumilin" hreflang="en">Elisabeth Szumilin</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>It seemed appropriate to assemble these texts now, at a time when the history of our AIDS missions is compelling us to formulate new goals. </p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" rel="tag" title="AIDS: A new pandemic leading to new medical and political practices" hreflang="en">Read more<span class="visually-hidden"> about AIDS: A new pandemic leading to new medical and political practices</span></a></li></ul> </div> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=3552&amp;2=reading_list" token="RPoeg7VBK2WKtdcdQtMPKugQ8UkZkPxOsxkr_eY9IRQ"></drupal-render-placeholder> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="8755" role="article" about="/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa" class="node node--type-notebook node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2020-06/MSF207011%28High%29.jpg?h=7fca5932&amp;itok=e7Q2R3Iy" width="450" height="300" alt="Painting &quot;Tuko Poa&quot; benches in Kibera" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Bryan Jaybee</div> </article> </div> <a href="/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa" class="main-link"></a> </div> <div class="group-content"> <div class="bundle-container"><div class="field--name-field-bundle">Cahier</div></div><span class="field field--name-title field--type-string field--label-hidden"><h3><a href="/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa" hreflang="en">Representations of HIV and impact on care seeking among the men of Homa Bay, Kenya</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2020-06-09T12:00:00Z" class="datetime">09/06/2020</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/xavier-plaisancie" hreflang="en">Xavier Plaisancie</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>This study, conducted among the men of Homa Bay in Nyanza Province, Kenya, assesses the representations of HIV and impact on care seeking. It reveals that simply setting up a testing or care campaign does not necessarily mean that the entire population will participate; the message has to be tailored to the target population and fine-tuned even within that population.</p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa" rel="tag" title="Representations of HIV and impact on care seeking among the men of Homa Bay, Kenya" hreflang="en">Read more<span class="visually-hidden"> about Representations of HIV and impact on care seeking among the men of Homa Bay, Kenya</span></a></li></ul> </div> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=8755&amp;2=reading_list" token="gYkkWhokU1gI7haI37P04bUgXkvTq5A_PqMA91vGP-U"></drupal-render-placeholder> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="12318" role="article" about="/en/publications/medicine-and-public-health/what-aids-teaches-us" typeof="schema:Article" class="node node--type-article node--view-mode-teaser"> <span property="schema:name" content="What AIDS teaches us" class="rdf-meta hidden"></span> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2022-09/MSB113908%28High%29.jpg?itok=XBGBcKR0" width="450" height="300" alt="image ce que nous dit le sida" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Njiiri Karago/MSF </div> </article> </div> <a href="/en/publications/medicine-and-public-health/what-aids-teaches-us" class="main-link"></a> </div> <div class="group-content"> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=12318&amp;2=reading_list" token="Aa00Wsg0JV5FG8KzvvI9ILeXwsiSJUHXEwcga5JzVnE"></drupal-render-placeholder><div class="bundle-container"><div class="field--name-field-bundle">Article</div></div><span property="schema:name" class="field field--name-title field--type-string field--label-hidden"><h3><a href="/en/publications/medicine-and-public-health/what-aids-teaches-us" hreflang="en">What AIDS teaches us</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2022-09-16T12:00:00Z" class="datetime">16/09/2022</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/rony-brauman" hreflang="en">Rony Brauman</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>In this article, Rony Brauman identifies the dynamics and events that made bending the HIV/AIDS epidemic curve possible. He explains the climate in which the tug-of-war with parts of the pharmaceutical industry played out from MSF’s perspective, and recalls that fears about international security and political stability also helped push governments to mobilise against the epidemic.</p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/en/publications/medicine-and-public-health/what-aids-teaches-us" rel="tag" title="What AIDS teaches us" hreflang="en">Read more<span class="visually-hidden"> about What AIDS teaches us</span></a></li></ul> </div> </div> </div> </article> </div> </div> </div> <div class="contribution-container"> <div class="field--name-field-contribution"> <p> <span>If you want to criticize or develop this content,</span> you can find us on twitter or directly on our site. </p> <a href="/en/contribute?to=12438" class="button">Contribute</a> </div> </div> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=12438&amp;2=reading_list" token="AaQl_rSPp0CPUPvW20vblzpMc9BLMj3zZyPj2WKvsNE"></drupal-render-placeholder><span class="field field--name-title field--type-string field--label-above">Controlling an HIV Hotspot. A Realistic Ambition? </span> Wed, 02 Nov 2022 11:53:36 +0000 elba.msf 12438 at https://msf-crash.org Ce que nous dit le sida https://msf-crash.org/fr/publications/medecine-et-sante-publique/ce-que-nous-dit-le-sida <div class="field field--name-field-publish-date field--type-datetime field--label-inline clearfix"> <div class="field__label">Date de publication</div> <div class="field__item"><time datetime="2022-09-16T12:00:00Z" class="datetime">16/09/2022</time> </div> </div> <span rel="schema:author" class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/en/user/125" typeof="schema:Person" property="schema:name" datatype="">elba.msf</span></span> <span property="schema:dateCreated" content="2022-10-06T08:41:09+00:00" class="field field--name-created field--type-created field--label-hidden">Thu, 10/06/2022 - 10:41</span> <div class="field field--name-field-tags field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/tags/aids" property="schema:about" hreflang="en">AIDS</a></div> <div class="field__item"><a href="/fr/tags/vih" property="schema:about" hreflang="fr">VIH</a></div> <div class="field__item"><a href="/en/tags/pharmaceutical-industry" property="schema:about" hreflang="en">pharmaceutical industry</a></div> </div> <details class="field--type-entity-person js-form-wrapper form-wrapper"> <summary role="button" aria-expanded="false" aria-pressed="false">Rony Brauman</summary><div class="details-wrapper"> <div class="field--type-entity-person js-form-wrapper form-wrapper field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"> <article data-history-node-id="3221" role="article" about="/index.php/en/rony-brauman" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-04/DSCF4256.jpg?itok=nCrBsaSM" width="180" height="230" alt="Rony Brauman" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Rony</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Brauman</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Medical doctor, specialized in tropical medicine and epidemiology. Involved in humanitarian action since 1977, he has been on numerous missions, mainly in contexts of armed conflicts and IDP situations. President of Médecins sans Frontières from 1982 to1994, he also teaches at the Humanitarian and Conflict Response Institute (HCRI) and is a regular contributor to Alternatives Economiques. He has published several books and articles, including&nbsp;"Guerre humanitaires ? Mensonges et Intox" (Textuel, 2018), "La Médecine Humanitaire" (PUF, 2010), "Penser dans l'urgence" (Editions du Seuil, 2006) and "Utopies Sanitaires" (Editions Le Pommier, 2000).</p> </div> <div class="same-author-link"><a href="/index.php/en/rony-brauman" class="button">By the same author</a> </div> </div> </div> </article> </div> </div> </div> </details> <div class="clearfix text-formatted field field--name-field-body field--type-text-long field--label-hidden field__item"><p class="MsoNormal"><em><span lang="EN-US">On Friday, 21 January 2022, Rony Brauman took part in the Académie des Sciences d’Outre-Mer and Académie Nationale de Médecine’s joint session on the stakes and challenges of healthcare globalisation. This article is an edited transcript of his talk; the video is also available <a href="https://msf-crash.org/fr/le-crash-dans-les-medias/ce-que-nous-dit-le-sida-intervention-de-rony-brauman-lacademie-nationale" target="_blank">on our website</a> (in French).</span></em><span lang="EN-US"><o:p></o:p></span></p> <p class="MsoNormal"><em><span lang="EN-US">In this presentation he identifies the dynamics and events that made bending the HIV/AIDS epidemic curve possible. He explains the climate in which the tug-of-war with parts of the pharmaceutical industry played out from MSF’s perspective, and recalls that fears about international security and political stability also helped push governments to mobilise against the epidemic.</span></em><br /> <span lang="EN-US"><o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Chairpersons and permanent secretaries of both assemblies,<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Ladies and gentlemen,<o:p></o:p></span></p> <p class="MsoNormal">&nbsp;</p> <h3 class="MsoNormal"><span lang="EN-US">Introduction<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">I would like to thank Dr. Chippaux, along with the chairpersons and permanent secretaries of both Academies for the opportunity to share the secrets that AIDS has taught me, if the Chair of the National Academy of Medicine’s announcement is to be believed.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Naturally, this disease has told me very few secrets. However, I’ve been able to follow, as a collective practitioner – that is, a member of a medical aid organisation that was deeply involved in the HIV epidemic – the many issues that came up at that time, and we are well-positioned to see the extent to which epidemics create questions or new problems. <o:p></o:p></span></p> <h3 class="MsoNormal"><span lang="EN-US">Range of issues revealed by the AIDS epidemic<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">I could, for example, have discussed a new and quite interesting medical situation – namely, the birth of what we now call “health democracy”. It manifests as a significantly greater involvement of patients and their loved ones in defining clinical trial protocols, and even their ethical framework, which had previously been the exclusive domain of medical practitioners. The extent to which health democracy has infiltrated other areas of medical practice is still up for debate, but this new way of doing things – which has allowed real advances in health care – began with AIDS.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">By the same token, it would have been totally possible to highlight the very rapid advances in knowledge. From the early 1980s, when a new, completely unknown syndrome</span><span class="annotation"><span lang="EN-US">In the beginning it was dubbed the “gay cancer”.</span></span><span lang="EN-US"><o:p></o:p></span><span lang="EN-US">that was initially fatal within a few months or years appeared, to the discovery of its viral origins and development of effective treatments that turned this terrible disease into a chronic condition with which it is possible to lead a nearly normal life, only fifteen years had passed.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">I could also – and this is an opportunity for me to discuss what I feel are essential medical and public health issues – have talked to you about the history of AIDS as an iatrogenic disease. The role of large scale public health campaigns in the epidemic’s explosion – I’m thinking of the first sleeping sickness campaigns in the 1920s and ‘30s and the widespread use of infusions and vaccination shots in the 1960s and ‘70s – seems much more important than the supposed sexual frenzy of Africans, a racist, colonialist view that is far from the reality, which is more prosaic and disturbing.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">I could also – and I’ll stop the litany of subjects that I will not be talking about there – have pointed to the WHO’s feeble response, its inertia reminiscent of the one it showed during the 2014 Ebola epidemic. That feeble response was more or less made up for – with many disadvantages and a few advantages – by the proliferation of institutions like UNAIDS (1995), the Global Fund (2002) and UNITAID (2006), institutions that in some way filled the vacuum left by the WHO.</span></p> <h3 class="MsoNormal"><span lang="EN-US">Access to antiretrovirals (ARVs)<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">I’ve decided to take a different angle for the analysis – that of a private humanitarian actor, Médecins Sans Frontières (MSF), engaged in a campaign to expand access to antiretrovirals.<span style="mso-spacerun:yes">&nbsp; </span>I will revisit the tug-of-war that was going on at the time with several institutions and especially with some in the pharmaceutical industry. As I mentioned at the start of my talk, antiretroviral therapies – which are highly effective against AIDS – were produced and administered starting in 1995-96. However, for business reasons – to protect intellectual property and compartmentalise the pharmaceutical markets – those drugs were reserved for patients in the Global North. To combat that worldwide “healthcare apartheid”, a number of NGOs (Oxfam, Treatment Action Campaign, and MSF, in particular) launched a campaign using the slogan, “The patients are in the South, the medicines are in the North”.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Obviously there were patients in the North, but it was largely in Africa that the epidemic had progressed to the point of killing millions of people. Remember, for example, that of the thirteen million documented AIDS orphans in the world in the late 1990s, twelve million were living in Africa. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">The campaign ran into strong opposition from the pharmaceutical industry. The porousness between political authority and the pharmaceutical industry raises many questions – and the Covid-19 pandemic in no way contradicts this; on the contrary, just look (for example) at the policy on vaccine prices today and the stunning, outrageous profits that private companies are making using the results of publicly-funded research. The pharmaceutical industry used two types of arguments to justify the draconian rationing of ARVs: a public health argument and an economic argument.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">The public health argument cast doubt on the capacity for treatment compliance by mostly illiterate patients who didn’t have a watch, which supposedly rendered them incapable of following a long-term regimen requiring them to both take their medicines at a set time, without forgetting, and abide by the constraints of disease follow-up. In brief, they were allegedly incapable of understanding where their interests lie, with the result – due to irregular, and thus ineffective, dose-taking – that resistant strains of the virus</span><span class="annotation"><span lang="EN-US">John Donnelly, “Prevention urged in AIDS fight. Natsios says fund should spend less on HIV treatment”, Boston Globe, 7 June 2001.</span></span><span lang="EN-US"><o:p></o:p>would be created. There we find two lines of argument analysed by Albert Hirschmann – futility and jeopardy – typically used to argue against granting new rights</span><span class="annotation"><span lang="EN-US"><em>The Rhetoric of Reaction: Perversity, Futility Jeopardy</em>, Harvard College, 1991.</span></span><span lang="EN-US">; not only would ARVs have little or no effect for African patients, but dispensing them would threaten the outcome for other patients.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">That policy had already prevailed with regard to tuberculosis until the early 2000s. A large number of TB patients who could have been treated were literally condemned to death by the slogan “better not treat than mistreat”. This was done to tens of thousands of patients based on the assumption that they were incapable of properly following a treatment protocol that, at the time, took six months to a year. So while the objection wasn’t new, it had particularly severe consequences, given the scale and progression of the AIDS epidemic globally. MSF took it upon itself to show that the noncompliance argument, and thus the threat of ARV resistance, was based on assumption, not observation. And we won that bet; today, the level of compliance in the AIDS programmes we support in Africa is quite good, with clinical results, impact on containment of the epidemic, and increase in life expectancy that are quite comparable to what we see in developed countries.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">The second argument, which was in some sense an extension of the first, had to do with protecting intellectual property to ensure funding for new drug research. According to pharmaceutical industry representatives, generic ARV production would threaten the industry’s capacity for innovation. Recall that in 1994, when the WTO was created, the principles of trade law were applied to intellectual property rights, prohibiting developing countries from producing generic forms of new medications. Those agreements were renegotiated in the early 2000s to facilitate implementation of compulsory licensing in case of healthcare-related need. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">While pharmaceutical research indisputably requires significant financing, it is helpful to remember that: 1/ most of the major drug classes discovered prior to the mid-1970s – in other words, a good part of the treatment arsenal still in use today – were produced without patent protection; and 2/ many of those drugs were developed via publicly-funded research, which is the case for ARVs, in particular, which came out of publicly-funded labs in the United States.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Bent on protecting their patents, the drug industry was determined to fight those whom Bill Gates once called “some new modern-day sort of communists […] under various guises</span><span class="annotation"><span lang="EN-US">Interview given to <em>News.com</em> on 5 January 2005 on the sidelines of the Consumer Electronics Show in Las Vegas.</span></span><span lang="EN-US">”.<o:p></o:p></span></p> <h3 class="MsoNormal"><span lang="EN-US">The Pretoria lawsuit<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">It was in this context of stark economic and political polarisation that an event that would apparently turn the tide occurred. In 2001, thirty-nine pharmaceutical companies decided to sue the South African government, which had arranged for what is called “parallel importation”</span><span class="annotation"><span lang="EN-US">This term refers to the importation of a product, in this case ARVs, without the permission of the intellectual property right-holder.</span></span><span lang="EN-US">, considered illegal, of ARVs from India. India has a large pharmaceutical industry – manufacturing generic drugs, in particular – that is among India’s national values, like Renault and the CEA were once national values in France. India, sometimes nicknamed “the pharmacy of the third world”, was supplying ARVs to South Africa, which was, as we know, especially hard-hit by the AIDS epidemic. For their part, the South African government had been wreathed in the halo of apartheid’s dismantlement, and was still glowing with the presidency of Nelson Mandela, who had left power in 1999 but remained on the political scene. Despite the positions of President Thabo Mbeki, who disputed the viral origin of AIDS, the government was still enjoying an aura that, though well faded in recent years, was still remarkable when the lawsuit began.<span style="mso-spacerun:yes">&nbsp; </span><o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">A robust international campaign supported by most of the media was set in motion by numerous associations and NGOs, including MSF, Oxfam, and Treatment Action Campaign. The latter, though less well-known than MSF and Oxfam, is a large South African association. Led by activists from the ANC (African National Congress), in particular, most of them former anti-apartheid activists, it enjoyed considerable political legitimacy and an aura of integrity, and conducted an extraordinary mobilisation effort. In addition, some of its leaders, themselves HIV-positive, had declared publicly that they were refusing treatment until ARVs were available to everyone in their country; they were literally placing their lives on the line. That gives an idea of the fervour and intensity of the local mobilisation</span><span class="annotation"><a href="https://msf-crash.org/en/publications/agir-tout-prix-negociations-humanitaires-lexperience-de-msf/i-stories#south-africa.-msf,-an-african-ngo?" target="_blank"><span lang="EN-US">https://msf-crash.org/en/publications/agir-tout-prix-negociations-humanitaires-lexperience-de-msf/i-stories#south-africa.-msf,-an-african-ngo?</span></a></span><span lang="EN-US">.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">The campaign, whose slogan was “Drop the Case”, was a huge success, since the pharmaceutical companies did indeed withdraw. They dropped their case, pathetically giving in in the face of general condemnation, with some of their executives privately – and some even publicly – calling the case a catastrophic mistake and major public relations error. ARVs then became affordable, their cost falling by 99% thanks to the lifting of intellectual property rights; triple therapies went from ten thousand to a hundred dollars a year. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">The elimination of that financial barrier, combined with an unprecedented budgetary effort in the healthcare realm, has made large-scale deployment of remarkably effective resources to fight AIDS possible over the past twenty years. Let’s remember that treating a patient to the point of undetectable viral load also means interrupting future transmission. We should also note, in passing, that the pharmaceutical companies whose patents were lifted have seen no effect on their profits. The populations benefitting from this, not being creditworthy, were not a market the pharmaceutical companies would have unduly been deprived of. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Of the forty-some-odd million people now living with HIV, nearly thirty million are under treatment, and an estimated six million do not know their serological status. So the fight against AIDS isn’t over – will it ever be? – but considerable progress, undreamed of even a short time ago, has been made. <o:p></o:p></span></p> <h3 class="MsoNormal"><span lang="EN-US">Security issues<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">Were the tug-of-war between NGOs, patient organisations, and pharmaceutical companies and the turning of public opinion against the pursuit of profit sufficient to account for that victory? That’s the general tenor of the accounts about it from the organisations involved.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">It is in no way to deny the legitimacy and appropriateness of the fight led by those NGOs, and especially TAC, to doubt that such mobilisation, though necessary, was sufficient to reverse the course of events so abruptly. It is what is missing from that story that I’m going to talk briefly about now. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">Around the turn of the twenty-first century a series of reports from various sources were published pointing out the dangerous political consequences of the epidemic. I’m thinking of how UNAIDS began talking, in 1998, about infection rates that were five times higher in the African armed forces than in the civilian population</span><span class="annotation"><span style="mso-ansi-language:FR">“AIDS and the military”, May 1998, cited in “Le Sida en Afrique subsaharienne : perceptions d’un enjeu de sécurité internationale”, Fanny Chabrol, <em>La Revue internationale et stratégique</em>, No. 46, Summer 2002.</span></span><span lang="EN-US">. I am also – and perhaps especially – thinking of the conjunction of a CIA report</span><span class="annotation"><span lang="EN-US">“The global infectious disease threat and its implications for the United States”, National Intelligence Council, January 2000.</span></span><span lang="EN-US"><o:p></o:p>and a UN Security Council meeting in January 2000. By placing a health-related question on its agenda for the first time in its history, the Security Council was treating it as a global security issue of the utmost importance. According to Fanny Chabrol, US Ambassador to the United Nations Richard Holbrooke had “a decisive influence by demonstrating the correlation between HIV infection and international security”.</span><span class="annotation"><em><span lang="EN-US">Op. cit.</span></em></span><span lang="EN-US"><o:p></o:p>Echoing UNAIDS and its legendary director, Peter Piot, the American diplomat stressed that AIDS was hitting the urban and urbanised elite, professors, administrators, government ministers, air traffic controllers, police, soldiers, and peacekeeping forces – that is, the very people who ensure the stability and continuity of government infrastructure. This convergence of security fears – more than humanitarian concerns – resulted in the largest public health budget ever devoted to a disease, the President’s Emergency Plan for AIDS Relief (PEPFAR). Passed in 2003, PEPFAR has thus far committed more than a hundred billion dollars to fighting AIDS</span><span class="annotation"><a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/" target="_blank"><span lang="EN-US">https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/</span></a></span><span lang="EN-US">. <o:p></o:p></span></p> <h3 class="MsoNormal"><span lang="EN-US">Foundations and convergence of currents of thought<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">This is not to contrast a passionate social movement led by civil society organisations with the cold pragmatic policy spearheaded by the United States, but rather to observe that the availability of effective, affordable treatments was made possible by a unique combination of circumstances: significant scientific progress (virus identification and ARV development), humanitarian mobilisation supported by public opinion and the media, and finally security fears that prompted governments – the most powerful one, in particular – to intervene. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US">So it was where the scientific, the social, and the political intersected that this progress was achieved – a configuration seen before under other circumstances and described, in particular, by anthropologist Didier Fassin</span><span class="annotation"><span style="mso-ansi-language:FR"><em>L’Espace politique de la santé, Essai de généalogie</em>, PUF, 1996.</span></span><span lang="EN-US">. He noted that the first population that public health took an interest in was the infants of poor families, in the late nineteenth century. He wondered why what some called “the massacre of innocents” – so high was the mortality rate – left the realm of the inexorable to become a cause for concern requiring that measures be taken. The author saw several converging reasons for that profound change. The first was the decline in the birth rate and resulting demographic weakening, which worried the government in a context where recovery vis-à-vis Germany after its victory in the Franco-Prussian War and the need for manpower to exploit colonial lands presented strategic challenges. Next was the philanthropic movement – especially in Christian progressive circles – in a context of growing inequality and enormous poverty, in which humanitarian associations proliferated. And lastly there was scientific progress – the discovery of microbes as the cause of infection, which led to pasteurisation of the milk given to infants and sterilisation of baby bottles, which reduced their mortality rate, especially in summertime. The “<em>Œuvre de la goutte de lait</em>”, founded in 1895, is a remarkable illustration of this. The distribution of pasteurised milk to infants after consultation and provision of childcare classes for mothers constituted both a medical and moral programme that spread widely in France and continued in some regions into the 1970s. Scientific discoveries, philanthropic movements, and political interests have thus created a new kind of space inside which innovations can be transformed into large-scale social practices.<o:p></o:p></span></p> <h3 class="MsoNormal"><span lang="EN-US">A few words in conclusion<o:p></o:p></span></h3> <p class="MsoNormal"><span lang="EN-US">This model shows us the conditions that are necessary, but not sufficient – almost imperative, however – to paradigm change. But it has its limits; it tells us nothing, of course, about important phenomena like the passionate commitment of the first medical teams confronted with this mysterious disease, or other political obstacles that hindered the start of AIDS control programmes. Hence to the various themes I mentioned at the start of my talk I could have added local governance and corruption, issues that were mentioned in other talks in this symposium in terms of the Ebola and COVID epidemics – in the DRC, in particular, where there have been massive diversions of billions of dollars. The local populations, aware of and outraged by this predation, protest and take it out on healthcare teams that are not necessarily involved in the theft but pay the price for it. There again, we see the extent to which the fight against epidemics extends to all aspects of politics, right down to ground level. But that’s another story, which I won’t go into. So I’m going to stop there by thanking you for your attention.<o:p></o:p></span></p> <p>&nbsp;</p> </div> <div class="citation-container"> <div class="field--name-field-citation"> <p> <span>To cite this content :</span> <br> Rony Brauman, What AIDS teaches us, 16 September 2022, URL : <a href="https://msf-crash.org/en/publications/medicine-and-public-health/what-aids-teaches-us">https://msf-crash.org/en/publications/medicine-and-public-health/what-aids-teaches-us</a> </p> </div> </div> <div class="height-computed field field--name-field-related-content field--type-entity-reference field--label-above"> <div class="field__label">Publications associées</div> <div class="field__items"> <div class="field__item"> <article data-history-node-id="6995" role="article" about="/en/conferences-debates/20th-anniversary-msf-access-campaign" class="node node--type-debate node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field 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href="/index.php/fr/publications/medecine-et-sante-publique/sida-des-traitements-pour-tous-vite" hreflang="fr">Sida, des traitements pour tous, vite</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2008-09-01T12:00:00Z" class="datetime">01/09/2008</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/index.php/fr/rony-brauman" hreflang="fr">Rony Brauman</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>Le nombre de malades sous traitements augmente rapidement constate Rony Brauman qui expose les progrés de ces dernières années et détaille les raisons supplémentaires de poursuivre dans ce sens.</p> <p> </p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/index.php/fr/publications/medecine-et-sante-publique/sida-des-traitements-pour-tous-vite" rel="tag" title="Sida, des traitements pour tous, vite" hreflang="fr">Read more<span class="visually-hidden"> about Sida, des traitements pour tous, vite</span></a></li></ul> </div> </div> </div> </article> </div> </div> </div> <div class="contribution-container"> <div class="field--name-field-contribution"> <p> <span>If you want to criticize or develop this content,</span> you can find us on twitter or directly on our site. </p> <a href="/en/contribute?to=12318" class="button">Contribute</a> </div> </div> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=12318&amp;2=reading_list" token="Aa00Wsg0JV5FG8KzvvI9ILeXwsiSJUHXEwcga5JzVnE"></drupal-render-placeholder><span class="field field--name-title field--type-string field--label-above">What AIDS teaches us</span> Thu, 15 Sep 2022 15:33:38 +0000 elba.msf 12318 at https://msf-crash.org De la possibilité de contrôler un foyer épidémique de VIH https://msf-crash.org/fr/publications/medecine-et-sante-publique/de-la-possibilite-de-controler-un-foyer-epidemique-de-vih <div class="field field--name-field-publish-date field--type-datetime field--label-inline clearfix"> <div class="field__label">Date de publication</div> <div class="field__item"><time datetime="2021-11-14T12:00:00Z" class="datetime">14/11/2021</time> </div> </div> <span rel="schema:author" class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/en/user/125" typeof="schema:Person" property="schema:name" datatype="">elba.msf</span></span> <span property="schema:dateCreated" content="2022-10-03T09:10:52+00:00" class="field field--name-created field--type-created field--label-hidden">Mon, 10/03/2022 - 11:10</span> <div class="field field--name-field-tags field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/fr/tags/vih" property="schema:about" hreflang="fr">VIH</a></div> <div class="field__item"><a href="/en/tags/aids" property="schema:about" hreflang="en">AIDS</a></div> <div class="field__item"><a href="/en/tags/humanitarian-medicine" property="schema:about" hreflang="en">humanitarian medicine</a></div> <div class="field__item"><a href="/en/tags/antiretroviral" property="schema:about" hreflang="en">antiretroviral</a></div> <div class="field__item"><a href="/en/tags/epidemic" property="schema:about" hreflang="en">epidemic</a></div> </div> <details class="field--type-entity-person js-form-wrapper form-wrapper"> <summary role="button" aria-expanded="false" aria-pressed="false">Elba Rahmouni, Pierre Mendiharat &amp; Léon Salumu Luzinga</summary><div class="details-wrapper"> <div class="field--type-entity-person js-form-wrapper form-wrapper field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"> <article data-history-node-id="5258" role="article" about="/en/elba-rahmouni" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2020-06/IMG_0562%20OK.jpg?itok=EI3BSai1" width="180" height="230" alt="Elba Rahmouni" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Elba</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Rahmouni</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><span><span>Since April 2018, Elba has been in charge of dissemination at CRASH. Elba holds a Master's degree in History of Classical Philosophy and a Master's degree in editorial consulting and digital knowledge management. During her studies, she worked on moral philosophy issues and was particularly interested in the practical necessity and the moral, legal and political prohibition of lying in Kant's philosophy.</span></span></p> </div> <div class="same-author-link"><a href="/en/elba-rahmouni" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="4202" role="article" about="/en/pierre-mendiharat" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Pierre</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Mendiharat</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Deputy Head of Operations, MSF France</p> </div> <div class="same-author-link"><a href="/en/pierre-mendiharat" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="11061" role="article" lang="fr" about="/fr/leon-salumu-luzinga" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Léon </div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Salumu Luzinga</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Responsable des programmes à Médecins Sans Frontières, Centre opérationnel de Paris (OCP)</p> </div> <div class="same-author-link"><a href="/en/node/11061" class="button">By the same author</a> </div> </div> </div> </article> </div> </div> </div> </details> <div class="clearfix text-formatted field field--name-field-body field--type-text-long field--label-hidden field__item"><p><em>This article was first released in the 18th volume of the <a href="https://alternatives-humanitaires.org/en/2021/11/14/about-the-possibility-of-controlling-an-hiv-epidemic-hotspot/" target="_blank">Humanitarian Alternatives magazine</a>.<br /> <br /> Designed to reduce the incidence of HIV/AIDS in a Kenyan district, a&nbsp;Médecins Sans Frontières&nbsp;project successfully exceeded the “90-90-90” target set by UNAIDS. A look back on the results that the authors of this article - Pierre Mendiharat, Deputy director of operations at MSF France and Léon Salumu Luzinga, Program manager at MSF France, interviewed by Elba Rahmouni - believe are encouraging but by no means a guarantee that the epidemic will be over by 2030.</em></p> <p>Despite strong international mobilisation over the last decades that has enabled significant advances in the fight against the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), the disease continues to kill on a massive scale, as is the case in Kenya, in the rural district of Ndhiwa in the county of Homa Bay.<span class="annotation">Kenya has been composed of forty-seven counties, each divided into districts, since the decentralisation of power introduced by the new constitution adopted in 2010. The ancient province of Nyanza, situated on the shore of Lake Victoria in the southwest of Kenya, includes the county of Homa Bay, itself divided into eight districts, including the district of Ndhiwa.</span>Although there is still no definite treatment or vaccine, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set itself the ambitious goal of ending the HIV/AIDS epidemic by 2030, in particular through the implementation of the strategy known as the “90-90-90” target (or “treatment cascade”): 90% of all people living with HIV should know their HIV status, 90% of all people with diagnosed HIV infection should receive sustained antiretroviral therapy (ART) and 90% of all people receiving ART should have viral suppression. These bold claims were put to the test in a five-year programme launched in 2014 by Doctors Without Borders (Médecins sans frontières&nbsp;–&nbsp;MSF) and Kenya’s Ministry of Health in the district of Ndhiwa. Previously, the Ndhiwa HIV Impact in Population Survey&nbsp;1 (NHIPS&nbsp;1) conducted by&nbsp;Épicentre&nbsp;(MSF’s epidemiology centre) in 2012 had brought to light HIV incidence and prevalence figures amongst the highest in the world. Six years later, a new&nbsp;Épicentre&nbsp;study, NHIPS 2 <span class="annotation">Médecins Sans Frontières, VIH : l’amélioration de la prise en charge a fait chuter la proportion des personnes infectées dans l’un des foyers les plus touchés au monde, 24 novembre 2020, <a href="https://www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus" target="_blank">https://www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus</a></span>, demonstrated that the “90-90-90” target had been exceeded. With incidence in significant decline, yet still elevated, can this truly be considered a success?</p> <p><strong>The Ndhiwa project: simplifying the treatment model</strong></p> <p>The Ndhiwa project was designed with the objective of reducing HIV incidence<span class="annotation">The incidence of a disease is the number of new cases occurring in a population during a specified period.</span> in the district by implementing every known biomedical method,&nbsp;i.e.&nbsp;mass testing, medical male circumcision <span class="annotation">MSF abandoned male circumcision campaigns as participation levels were too low. Other organisations were conducting circumcision campaigns with better results.</span>, early treatment initiation of HIV-positive persons and proper care and medical monitoring of patients to ensure that their viral load remains undetectable. The population-based approach involved working with Ndhiwa’s entire population, not simply with a cohort of patients. During the first two years (2014 and 2015), MSF deployed significant resources in Ndhiwa’s villages, conducting awareness-raising and testing campaigns outside of health facilities as well as increasing the capacities of health facilities. Awareness-raising and testing campaigns enabled hard-to-reach populations to be accessed, in particular men who did not regularly attend health facilities. Then, from 2016, the team worked on decentralising delivery of care and laboratory practices in the district as well as simplifying the care pathway. In 2018, after testing the population of the entire district, the team pursued testing activities within the health facilities, saving home-based testing for the contacts (family and friends) of all persons tested positive in health care facilities.</p> <p>In conjunction, a care delivery simplification process was launched, for example spacing out consultations to reduce the overall number of appointments. In a country in which the health care system faces staff shortages, it was important to reduce the workload of the teams monitoring cohorts of thousands of patients so that they could focus on the quality of consultations. From the patient’s point of view, travelling to health facilities less frequently can be advantageous as it lessens the burden of time and money. MSF thus proposed clinical consultations once every six months and introduced the option of collecting medication refills once every three months. MSF teams also set up Community ART Groups (CAGs) in remote villages whereby patients form a group and each group member travels to a consultation once a year and brings home medication for the other patients in their group. In the last few years, MSF has been implementing the Differentiated Service Delivery Model (DSDM) where, rather than imposing a model of care to all patients, patients can choose their care pathway from a number of different options.</p> <p><strong>Partnering with Kenya’s Ministry of Health and local populations</strong></p> <p>MSF was determined from the outset that its action would be both long-term (since HIV treatment and care is lifelong) and replicable. From working with the Kenyan Ministry of Health, the team revised its standards to adapt to on-the-ground realities, particularly regarding the number of healthcare workers, protocols and remuneration. By demonstrating that HIV transmission could be impacted at a population level, the organisation hoped that health authorities would do the same in other districts. In addition, this project was very ambitious in terms of community mobilisation, as the entire adult population had to be tested every year&nbsp;<span class="annotation">When encouraging people to be tested, the devastation caused by discovering one’s seropositivity must never be underestimated. Consequences upon emotional, family and sexual life inevitably add to the fear of illness and death. Yet the organisation has no doubt benefited from a significant development: the HIV epidemic had become so widespread in this region that stigmatisation had become inverted. One quarter of adults are HIV-positive, and, amongst the three quarters of HIV-negative adults, everybody has personally known – or still knows – more than one HIV-positive individual.</span>. There was therefore a need for concerted action with the authorities, including the Ministry of Health, traditional chiefs and local notables. The participation of these influential figures was a key criterion of the project’s success.</p> <p>While MSF claims to work with ministries of Health, in practice MSF teams often seek to create positions for themselves within health systems so that they can work as autonomously as possible. The organisation has historically managed to remain as independent as possible –&nbsp;above all financially&nbsp;–, which has been instrumental to its success. However, the downside of this approach is that it has turned MSF staff into notorious isolationists, with a limited ability to work successfully in partnership. Yet nowadays there are so many contexts in which MSF would benefit from operational partnerships, certainly more so than thirty years ago. Indeed, in the last three decades, the capacities of countries of intervention and of other humanitarian aid stakeholders have increased significantly. Consequently, the organisation is trying to tackle its isolationism. For the Ndhiwa project, MSF teams therefore sought to work in a participatory fashion from the outset, forming technical committees and steering committees within which the Ministry of Health, MSF and other district HIV stakeholders had to make concerted decisions. However, the MSF head of mission present at the beginning of the project explained that he continually struggled with his MSF colleagues to bring the decision-making process timeframes in line with the consultation time required with other stakeholders.</p> <p><strong>Community mobilisation and the health care worker/patient relationship</strong></p> <p>For many years, international programmes to fight HIV have been shaped by attempts to change population behaviour, with strategies ranging from directives to encourage abstinence (in particular in all the programmes funded by the President’s Emergency Plan for AIDS Relief<span class="annotation">President’s Emergency Plan for AIDS Relief (PEPFAR): an emergency aid plan for combatting AIDS launched by the American president George W. Bush in 2003 [Editor’s note].</span>) to those promoting the reduction of the number of sexual partners and the systematic use of condoms. Even after the patent failure of such policies, these directives were overwhelmingly continued. This is particularly true in this part of Kenya where an anthropological literature established a link between the explosion of the HIV epidemic and traditional rites involving sexual acts within the Luo community. A study conducted by Xavier Plaisancie&nbsp;<span class="annotation">President’s Emergency Plan for AIDS Relief (PEPFAR): an emergency aid plan for combatting AIDS launched by the American president George W. Bush in 2003 [Editor’s note].</span> among Homa Bay County’s male population, clearly demonstrates a contradiction between the social expectations of normality and virility and public health messages, and showed how difficult it is for any individual to resolve these contradictions. MSF made it very clear that in Ndhiwa it wished to rely upon biomedical methods rather than venture onto this anthropological terrain.</p> <p>Relationships between healthcare workers and patients are by nature unbalanced, with healthcare workers frequently finding themselves delivering directives. To some extent, the activities conducted in Ndhiwa’s villages caused a rupture from these habitual dynamics and patterns. Indeed, this strategy contributed to the project’s success, as measured by the remarkable testing results. During the home-based visits, medical teams had to introduce themselves and then explain and justify what they were doing. As patients were welcoming healthcare workers into their own homes, they were empowered to ask all the questions they needed to understand while the healthcare workers took the time to provide answers, enabling patients to make informed choices. In health facilities, healthcare workers presume that if patients come to the facility they accept the various medical procedures, including testing.</p> <p>MSF has not yet sufficiently improved the health care worker/patient relationship in health facilities. Yet various recommendations and trainings systematically emphasise the importance of empathy, the act of listening, respect and non-judgement. The organisation may therefore reasonably hope that these trainings and recommendations will soon bear fruit. Nonetheless, evaluating healthcare worker/patient relationship quality in the field remains challenging. Rose Burns’s study&nbsp;<span class="annotation">Rose Burns et al.,“‘I saw it as a second chance’: A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretrovial therapy in Kenya, Malawi and Mozambique”, Global Public Health, vol.14, no.8, 2019, p.1112-1124, <a href="https://www.tandfonline.com/doi/full/10.1080/17441692.2018.1561921" target="_blank">https://www.tandfonline.com/doi/full/10.1080/17441692.2018.1561921</a></span> conducted with a cohort of Ndhiwa patients having encountered periods of treatment failure demonstrated the programme’s poor economic and social support as well as the inadequate personalisation of messaging and care to individual patients. Finally, it is regrettable that no robust mechanism was implemented for preventing and detecting patient abuse.</p> <p><strong>Highly encouraging results</strong></p> <p>This project was assessed by comparing the two previously cited studies (NHIPS 1 and 2). Results exceeded all expectations, demonstrating an improvement of the treatment cascade as well as a decrease in HIV incidence and prevalence. The 90-90-90 target was even exceeded as results of 93-97-95 were achieved respectively. This means that fewer than 12% of HIV-positive individuals have a detectable viral load and are potentially contagious, representing 16,000 people with access to effective treatment.</p> <p>Due to a statistical problem caused by overlapping confidence intervals <span class="annotation">In 2012, 95% probability of incidence between 1.1 and 2.5% per year. In 2018, 95% probability of incidence between 0.4 and 1.2% per year. Therefore there is an admittedly extremely low probability that – &nbsp;in both 2012 and 2018 – incidence fell somewhere between 1.1 and 1.2%.</span>, the question of whether the incidence of new infections had fallen was more challenging to answer. A much larger sample would have been required to guarantee the robustness of such a comparison. However, other factors did corroborate a reduction of HIV transmission. In 2018, 88% of HIV-positive individuals had an undetectable viral load and were therefore non contagious, compared to only 40% in 2012. Amongst young people between the ages of 15 and 24, prevalence fell in comparison to 2012. This is consistent with low HIV incidence within this age group. The project’s managers agreed on the likelihood that HIV incidence had declined in the years running up to 2018 and that the previously unseen and highly ambitious target of significantly reducing HIV transmission in the very place on the planet where the epidemic was most devastating had been reached. In the Ndhiwa district, MSF decided to tackle a very large endemic hotspot by deploying significant resources for a relatively small population (in 2015, the district counted 242,726 inhabitants). In light of the prevalence observed at Homa Bay, the organisation considered that such a mobilisation of resources, sometimes at the cost of other diseases, was justified.</p> <p><strong>MSF’s departure and the project today</strong></p> <p>Since the launch of the project in 2014, ensuring its continuity was considered a priority. Project coordinators therefore adopted Ministry of Health standards. All additional staff were recruited based upon Ministry standards, especially in relation to remuneration. MSF teams were responsible for mentoring, meaning providing long-term one-to-one coaching to healthcare workers. The team was convinced that the Kenyan healthcare system could maintain the treatment cascade without external partners. MSF’s concern is how to safeguard positive results in the context of the current Covid-19 pandemic and its associated restrictive measures. Vigilance is required, in particular for countries –&nbsp;such as Kenya&nbsp;– considered by the Global Fund to Fight AIDS, Tuberculosis and Malaria as having slightly higher economic capacities and therefore been identified for receiving reduced allocated funds.</p> <p>Furthermore, MSF continues to collaborate with other stakeholders to respond to the shortcomings and challenges identified: improving the treatment and care of adolescents (for whom the treatment failure rate is still around 20%) and patients with a failure treatment or patients requiring a third-line treatment regimen <span class="annotation">Patients failing a second-line treatment regimen are placed on a third-line treatment regimen, based upon genotypic resistance&nbsp;testing results.</span>. These patients are currently having to wait six to eight months before their treatment is modified. To reduce this delay, MSF favours a local decision-making process that does not go through a national committee (as recommended by the central level).</p> <p><strong>Avoiding easy slogans</strong></p> <p>The Ndhiwa project coincided with a key moment in the history of HIV research. In 2008, Swiss health authorities declared – in what was to become known as the Swiss Statement – that patients who took their treatment correctly were no longer contagious. This momentous announcement, particularly for serodiscordant couples<span class="annotation"> In a serodiscordant couple, one partner is infected by HIV and the other is not.</span>, sparked a double controversy at the International AIDS Society (IAS) conference held in Mexico City the same year. The question was raised as to whether the statement was based on sufficiently robust scientific research and, if so, whether patients should be informed. A few years later, in July 2011, the HPTN052 randomised study demonstrated that, within a cohort of serodiscordant couples, early ARV treatment initiation had led to a 96% decrease in HIV transmissions to the non-infected partners. From this corroboration of the Swiss Statement emerged the theory of the possible control of the HIV epidemic, as treatment becomes a means of prevention: if all HIV-positive persons have access to treatment, transmissions will cease <span class="annotation">Prevention programmes used to recommend exclusively the use of condoms or abstinence, two behaviours that have not managed to control the epidemic. In the absence of biomedical tools, public health policies called for changes in behaviour, i.e. a high level of discipline required from populations and uncertain results.</span>. Concretely, this requires urging the entire population to be tested, generalising access to treatment, entering into long-term relationships with patients and then observing whether this strategy leads to a decrease in incidence at the population level. This plan was completely theoretical, as although at the level of a cohort of serodiscordant couples the halting or drastic reduction of transmission had been demonstrated, this had never been proven at the population level.</p> <p>MSF endorsed the objectives summarised by the 90-90-90 slogan, which are simply a quantitative translation of good practices in fighting an epidemic: ensure access to diagnosis and treatment, provide high-quality care and achieve effective treatment. The question raised now is whether these objectives are sufficient: what about the remaining 10-10-10? Accepting these targets also means accepting that only 73% of HIV-positive people have an undetectable viral load. Indeed, UNAIDS now recommends a 95-95-95 treatment target <span class="annotation">UNAIDS, “Understanding Fast-Track, Accelerating action to end the aids epidemic by 2030”, June 2015, <a href="https://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_fr.pdf" target="_blank">https://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_fr.pdf</a></span>. At the outset of the Ndhiwa project in Kenya in 2014, and until the results of the NHIPS 2 epidemiological study were published, MSF was not certain that the 90-90-90 target was realistic, given the high level of individual and collective discipline required.</p> <p>Furthermore, contrary to the 90-90-90 targets, the eradication of HIV in 2030 has never been a part of MSF’s strategy. As a general rule, this type of objective differs from the organisation’s modus operandi, which focuses on projects with clearly defined aims. “The end of AIDS by 2030” is a slogan that has been used by UNAIDS since the IAS conference in Vienna in 2011 in order to re-engage donors in the face of what was perceived as “donor fatigue” (a fall in donations to fight the HIV epidemic). MSF should surely have distanced itself further from such a misleading slogan, as anybody studying HIV of course knows that we cannot hope to be done with HIV by 2030. MSF’s intention has always been to report on the reality of the disease, as illustrated by the lived experiences of patients, patient treatment failures, the challenges of everyday life and the still elevated death rate. This communication strategy has no doubt been implemented in an overly schematic fashion, without truly acknowledging the significant advances achieved elsewhere. The results of the NHIPS&nbsp;2 study suggest that these two imperatives may be reconciled.</p> <p class="text-align-right">Translated from the French by Naomi Walker</p> </div> <div class="citation-container"> <div class="field--name-field-citation"> <p> <span>To cite this content :</span> <br> Elba Rahmouni, Pierre Mendiharat, Léon Salumu Luzinga, About the possibility of controlling an HIV epidemic hotspot, 14 November 2021, URL : <a href="https://msf-crash.org/en/publications/medicine-and-public-health/about-possibility-controlling-hiv-epidemic-hotspot">https://msf-crash.org/en/publications/medicine-and-public-health/about-possibility-controlling-hiv-epidemic-hotspot</a> </p> </div> </div> <div class="height-computed field field--name-field-related-content field--type-entity-reference field--label-above"> <div class="field__label">Publications associées</div> <div class="field__items"> <div class="field__item"> <article data-history-node-id="6171" role="article" lang="fr" about="/fr/blog/medecine-et-sante-publique/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins" class="node node--type-blog-post node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2018-12/MSF203083%28High%29.JPG?h=7fca5932&amp;itok=w-Vvl_06" width="450" height="300" alt="Advanced HIV management in Homa Bay" title="Advanced HIV management in Homa Bay" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Patrick Meinhardt</div> </article> </div> <a href="/en/node/6171" class="main-link"></a> </div> <div class="group-content"> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=6171&amp;2=reading_list" token="Z6essrcHuq22_O29nHgu_jxjhZy4YpCh2zK8jpvy-DE"></drupal-render-placeholder><div class="bundle-container"><div class="field--name-field-bundle">Post de blog</div></div><span class="field field--name-title field--type-string field--label-hidden"><h3><a href="/fr/blog/medecine-et-sante-publique/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins" hreflang="fr">Les représentations du VIH et leur impact sur le recours aux soins. 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Enquête au sein de la population masculine de Homa Bay au Kenya</span></a></li></ul> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="12318" role="article" about="/en/publications/medicine-and-public-health/what-aids-teaches-us" typeof="schema:Article" class="node node--type-article node--view-mode-teaser"> <span property="schema:name" content="What AIDS teaches us" class="rdf-meta hidden"></span> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2022-09/MSB113908%28High%29.jpg?itok=XBGBcKR0" width="450" height="300" alt="image ce que nous dit le sida" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Njiiri Karago/MSF </div> </article> </div> <a href="/en/publications/medicine-and-public-health/what-aids-teaches-us" class="main-link"></a> </div> <div class="group-content"> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=12318&amp;2=reading_list" token="Aa00Wsg0JV5FG8KzvvI9ILeXwsiSJUHXEwcga5JzVnE"></drupal-render-placeholder><div class="bundle-container"><div class="field--name-field-bundle">Article</div></div><span property="schema:name" class="field field--name-title field--type-string field--label-hidden"><h3><a href="/en/publications/medicine-and-public-health/what-aids-teaches-us" hreflang="en">What AIDS teaches us</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2022-09-16T12:00:00Z" class="datetime">16/09/2022</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/rony-brauman" hreflang="en">Rony Brauman</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>In this article, Rony Brauman identifies the dynamics and events that made bending the HIV/AIDS epidemic curve possible. He explains the climate in which the tug-of-war with parts of the pharmaceutical industry played out from MSF’s perspective, and recalls that fears about international security and political stability also helped push governments to mobilise against the epidemic.</p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/en/publications/medicine-and-public-health/what-aids-teaches-us" rel="tag" title="What AIDS teaches us" hreflang="en">Read more<span class="visually-hidden"> about What AIDS teaches us</span></a></li></ul> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3552" role="article" about="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" class="node node--type-notebook node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2017-05/MSB16331.jpg?itok=Ed8fq3GK" width="450" height="300" alt="Département VIH/sida de l&#039;hôpital régional d&#039;Arua en Ouganda" title="Sida : nouvelle pandémie, nouvelles pratiques médicales et politiques" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Isabel Corthier</div> </article> </div> <a href="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" class="main-link"></a> </div> <div class="group-content"> <div class="bundle-container"><div class="field--name-field-bundle">Cahier</div></div><span class="field field--name-title field--type-string field--label-hidden"><h3><a href="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" hreflang="en">AIDS: A new pandemic leading to new medical and political practices</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2011-12-15T12:00:00Z" class="datetime">15/12/2011</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/index.php/en/joan-amondi" hreflang="en">Joan Amondi</a></div> <div class="field__item"><a href="/index.php/en/jean-herve-bradol" hreflang="en">Jean-Hervé Bradol</a></div> <div class="field__item"><a href="/index.php/en/vanja-kovacic" hreflang="en">Vanja Kovacic</a></div> <div class="field__item"><a href="/index.php/en/elisabeth-szumilin" hreflang="en">Elisabeth Szumilin</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>It seemed appropriate to assemble these texts now, at a time when the history of our AIDS missions is compelling us to formulate new goals. </p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" rel="tag" title="AIDS: A new pandemic leading to new medical and political practices" hreflang="en">Read more<span class="visually-hidden"> about AIDS: A new pandemic leading to new medical and political practices</span></a></li></ul> </div> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=3552&amp;2=reading_list" token="RPoeg7VBK2WKtdcdQtMPKugQ8UkZkPxOsxkr_eY9IRQ"></drupal-render-placeholder> </div> </div> </article> </div> </div> </div> <div class="contribution-container"> <div class="field--name-field-contribution"> <p> <span>If you want to criticize or develop this content,</span> you can find us on twitter or directly on our site. </p> <a href="/en/contribute?to=12358" class="button">Contribute</a> </div> </div> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=12358&amp;2=reading_list" token="cQ_f3QJUviVkxcsByiH7hHCepe1Hmb6lvbqSfRdg7hk"></drupal-render-placeholder><span class="field field--name-title field--type-string field--label-above">About the possibility of controlling an HIV epidemic hotspot</span> Mon, 03 Oct 2022 08:59:23 +0000 elba.msf 12358 at https://msf-crash.org Les représentations du VIH et leur impact sur le recours aux soins - Enquête au sein de la population masculine de Homa Bay au Kenya https://msf-crash.org/fr/publications/medecine-et-sante-publique/les-representations-du-vih-et-leur-impact-sur-le-recours <div class="field field--name-field-publish-date field--type-datetime field--label-inline clearfix"> <div class="field__label">Date de publication</div> <div class="field__item"><time datetime="2020-06-09T12:00:00Z" class="datetime">09/06/2020</time> </div> </div> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/en/user/125" typeof="schema:Person" property="schema:name" datatype="">elba.msf</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 06/09/2020 - 11:21</span> <div class="field field--name-field-tags field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/fr/tags/pdf" hreflang="fr">PDF</a></div> <div class="field__item"><a href="/en/tags/sociology" hreflang="en">sociology</a></div> <div class="field__item"><a href="/en/tags/humanitarian-medicine" hreflang="en">humanitarian medicine</a></div> <div class="field__item"><a href="/en/tags/aids" hreflang="en">AIDS</a></div> <div class="field__item"><a href="/fr/tags/vih" hreflang="fr">VIH</a></div> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/xavier-plaisancie" hreflang="en">Xavier Plaisancie</a></div> </div> <div class="clearfix text-formatted field field--name-field-body field--type-text-long field--label-hidden field__item"><p><em>This publication is also available as a <a href="https://www.msf-crash.org/sites/default/files/2021-07/Cahier_CRASH_VIH_KENYA_VA.pdf" target="_blank">PDF</a>. </em></p> <p><em>Medicine thesis defended in 2018, shorter version, supervised by Dr. Jean-Hervé Bradol and sociologist Marc Le Pape.</em></p> <p>After more than thirty years of combating HIV (human immunodeficiency virus) and despite progress in both treatment and reducing the stigmatization of people living with HIV (PLHIV), issues related to the epidemic persist.</p> <p>This is the reality in Nyanza Province, a rural area in western Kenya where this study was conducted. The prevalence in this region of 4.4 million inhabitants is an estimated 15%, and in some districts is as high as 25%. The mortality rate is also very high, due to AIDS (Acquired Immune Deficiency Syndrome) in particular.</p> <p>In a high-prevalence area, behavior change is often spurred by an individual’s awareness of the risk of infection, by testing, and by learning that he is HIV-positive. In particular, such change is reflected in the relationship between the sexes and in the demand for care. The individual then weighs the HIV-related risks against a whole set of health, social, and economic considerations. Hence there may be some process by which the risks and benefits of given behaviors are prioritized.</p> <p>At a time when there seems to be a great deal of pressure on the individual and societies to achieve the global objective of HIV eradication, it would seem important to include and support every individual in the health care effort and process. As we will see, simply setting up a testing or care campaign does not necessarily mean that the entire population will participate; the message has to be tailored to the target population and fine-tuned even within that population.</p> </div> <div class="field field--name-field-chapters field--type-entity-reference field--label-above"> <div class="field__label">Chapitres</div> <div class="field__items"> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-0" hreflang="en">Foreword</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-1" hreflang="en">Introduction</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-2" hreflang="en">Chapter 1 - Framework of the study</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-3" hreflang="en">Chapter 2 - Methods</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-4" hreflang="en">Chapter 3 - Results</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-5" hreflang="en">Chapter 4 - Discussion</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-6" hreflang="en">List of abbreviations</a></div> <div class="field__item"><a href="/en/publications/les-representations-du-vih-et-leur-impact-sur-le-recours-aux-soins-enquete-au-sein-de" hreflang="en">Bibliography</a></div> </div> </div> <div class="height-computed field field--name-field-related-content field--type-entity-reference field--label-above"> <div class="field__label">Publications associées</div> <div class="field__items"> <div class="field__item"> <article data-history-node-id="3552" role="article" about="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" class="node node--type-notebook node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2017-05/MSB16331.jpg?itok=Ed8fq3GK" width="450" height="300" alt="Département VIH/sida de l&#039;hôpital régional d&#039;Arua en Ouganda" title="Sida : nouvelle pandémie, nouvelles pratiques médicales et politiques" typeof="foaf:Image" class="image-style-teaser" /> </div> <div class="field field--name-field-copyright field--type-string field--label-hidden field__item">Isabel Corthier</div> </article> </div> <a href="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" class="main-link"></a> </div> <div class="group-content"> <div class="bundle-container"><div class="field--name-field-bundle">Cahier</div></div><span class="field field--name-title field--type-string field--label-hidden"><h3><a href="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" hreflang="en">AIDS: A new pandemic leading to new medical and political practices</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2011-12-15T12:00:00Z" class="datetime">15/12/2011</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/index.php/en/joan-amondi" hreflang="en">Joan Amondi</a></div> <div class="field__item"><a href="/index.php/en/jean-herve-bradol" hreflang="en">Jean-Hervé Bradol</a></div> <div class="field__item"><a href="/index.php/en/vanja-kovacic" hreflang="en">Vanja Kovacic</a></div> <div class="field__item"><a href="/index.php/en/elisabeth-szumilin" hreflang="en">Elisabeth Szumilin</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>It seemed appropriate to assemble these texts now, at a time when the history of our AIDS missions is compelling us to formulate new goals. </p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/index.php/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political" rel="tag" title="AIDS: A new pandemic leading to new medical and political practices" hreflang="en">Read 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href="/index.php/fr/publications/medecine-et-sante-publique/sida-des-traitements-pour-tous-vite" hreflang="fr">Sida, des traitements pour tous, vite</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2008-09-01T12:00:00Z" class="datetime">01/09/2008</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/index.php/fr/rony-brauman" hreflang="fr">Rony Brauman</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>Le nombre de malades sous traitements augmente rapidement constate Rony Brauman qui expose les progrés de ces dernières années et détaille les raisons supplémentaires de poursuivre dans ce sens.</p> <p> </p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/index.php/fr/publications/medecine-et-sante-publique/sida-des-traitements-pour-tous-vite" rel="tag" title="Sida, des traitements pour tous, vite" hreflang="fr">Read more<span class="visually-hidden"> about Sida, des traitements pour tous, vite</span></a></li></ul> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3876" role="article" lang="fr" about="/fr/publications/medecine-et-sante-publique/le-sida-maladie-detat" typeof="schema:Article" class="node node--type-article node--view-mode-teaser"> <span property="schema:name" content="Le SIDA, maladie d’Etat" class="rdf-meta hidden"></span> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img 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d’Etat</a></h3> </span> <div class="field field--name-field-publish-date field--type-datetime field--label-hidden field__item"><time datetime="2004-01-01T12:00:00Z" class="datetime">01/01/2004</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/fr/rony-brauman" hreflang="fr">Rony Brauman</a></div> </div> <div class="clearfix text-formatted field field--name-field-summary field--type-text-long field--label-hidden field__item"><p>Rony Brauman analyse la dimension politique de l'épidémie de Sida.</p> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/fr/publications/medecine-et-sante-publique/le-sida-maladie-detat" rel="tag" title="Le SIDA, maladie d’Etat" hreflang="fr">Read more<span class="visually-hidden"> about Le SIDA, maladie d’Etat</span></a></li></ul> </div> </div> </div> </article> </div> </div> </div> <div class="citation-container"> <div class="field--name-field-citation"> <p> <span>To cite this content :</span> <br> Xavier Plaisancie, Representations of HIV and impact on care seeking among the men of Homa Bay, Kenya, 9 June 2020, URL : <a href="https://msf-crash.org/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa">https://msf-crash.org/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa</a> </p> </div> </div> <div class="contribution-container"> <div class="field--name-field-contribution"> <p> <span>If you want to criticize or develop this content,</span> you can find us on twitter or directly on our site. </p> <a href="/en/contribute?to=8755" class="button">Contribute</a> </div> </div> <span class="field field--name-title field--type-string field--label-above">Representations of HIV and impact on care seeking among the men of Homa Bay, Kenya</span> Tue, 09 Jun 2020 09:21:18 +0000 elba.msf 8755 at https://msf-crash.org Lectures estivales https://msf-crash.org/fr/blog/guerre-et-humanitaire/lectures-estivales <div class="field field--name-field-publish-date field--type-datetime field--label-inline clearfix"> <div class="field__label">Date de publication</div> <div class="field__item"><time datetime="2017-07-03T12:00:00Z" class="datetime">03/07/2017</time> </div> </div> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/en/user/2" typeof="schema:Person" property="schema:name" datatype="">Agnes</span></span> <span class="field field--name-created field--type-created field--label-hidden">Fri, 07/07/2017 - 16:08</span> <div class="field field--name-field-tags field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/tags/migrations" hreflang="en">migrations</a></div> <div class="field__item"><a href="/en/tags/trypanosomiasis" hreflang="en">trypanosomiasis</a></div> <div class="field__item"><a href="/en/tags/colonial-medicine" hreflang="en">colonial medicine</a></div> <div class="field__item"><a href="/en/tags/european-union" hreflang="en">European Union</a></div> <div class="field__item"><a href="/en/tags/humanitarian-camp" hreflang="en">humanitarian camp</a></div> <div class="field__item"><a href="/en/tags/encampment" hreflang="en">encampment</a></div> <div class="field__item"><a href="/en/tags/military-intervention" hreflang="en">military intervention</a></div> <div class="field__item"><a href="/en/tags/anthropology" hreflang="en">anthropology</a></div> <div class="field__item"><a href="/en/tags/aids" hreflang="en">AIDS</a></div> <div class="field__item"><a href="/en/tags/epidemic" hreflang="en">epidemic</a></div> <div class="field__item"><a href="/en/tags/fight-against-inequalities" hreflang="en">fight against inequalities</a></div> <div class="field__item"><a href="/en/tags/calais" hreflang="en">Calais</a></div> <div class="field__item"><a href="/fr/tags/violence-politique" hreflang="fr">violence politique</a></div> </div> <details class="field--type-entity-person js-form-wrapper form-wrapper"> <summary role="button" aria-expanded="false" aria-pressed="false">Rony Brauman, Jean-Hervé Bradol, Michaël Neuman, Marc Le Pape, Judith Soussan &amp; Fabrice Weissman</summary><div class="details-wrapper"> <div class="field--type-entity-person js-form-wrapper form-wrapper field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"> <article data-history-node-id="3221" role="article" about="/index.php/en/rony-brauman" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-04/DSCF4256.jpg?itok=nCrBsaSM" width="180" height="230" alt="Rony Brauman" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Rony</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Brauman</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Medical doctor, specialized in tropical medicine and epidemiology. Involved in humanitarian action since 1977, he has been on numerous missions, mainly in contexts of armed conflicts and IDP situations. President of Médecins sans Frontières from 1982 to1994, he also teaches at the Humanitarian and Conflict Response Institute (HCRI) and is a regular contributor to Alternatives Economiques. He has published several books and articles, including&nbsp;"Guerre humanitaires ? Mensonges et Intox" (Textuel, 2018), "La Médecine Humanitaire" (PUF, 2010), "Penser dans l'urgence" (Editions du Seuil, 2006) and "Utopies Sanitaires" (Editions Le Pommier, 2000).</p> </div> <div class="same-author-link"><a href="/index.php/en/rony-brauman" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3222" role="article" about="/en/jean-herve-bradol" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-04/DSCF4265.jpg?itok=AmXSIDIp" width="180" height="230" alt="Jean-Hervé Bradol" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Jean-Hervé</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Bradol</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Medical doctor, specialized in tropical medicine, emergency medicine and epidemiology. In 1989 he went on mission with Médecins sans Frontières for the first time, and undertook long-term missions in Uganda, Somalia and Thailand. He returned to the Paris headquarters in 1994 as a programs director. Between 1996 and 1998, he served as the director of communications, and later as director of operations until May 2000 when he was elected president of the French section of Médecins sans Frontières. He was re-elected in May 2003 and in May 2006. From 2000 to 2008, he was a member of the International Council of MSF and a member of the Board of MSF USA. He is the co-editor of "Medical innovations in humanitarian situations" (MSF, 2009) and Humanitarian Aid, Genocide and Mass Killings: Médecins Sans Frontiéres, The Rwandan Experience, 1982–97 (Manchester University Press, 2017).</p> </div> <div class="same-author-link"><a href="/en/jean-herve-bradol" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3257" role="article" about="/index.php/en/michael-neuman" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-04/DSCF4167%20copie_0.jpg?itok=uJXHTXNJ" width="180" height="230" alt="Michaël Neuman" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Michaël</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Neuman</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Director of studies at Crash / Médecins sans Frontières, Michaël Neuman graduated in Contemporary History and International Relations (University Paris-I). He joined Médecins sans Frontières in 1999 and has worked both on the ground (Balkans, Sudan, Caucasus, West Africa) and in headquarters (New York, Paris as deputy director responsible for programmes). He has also carried out research on issues of immigration and geopolitics. He is co-editor of "Humanitarian negotiations Revealed, the MSF experience" (London: Hurst and Co, 2011). He is also the co-editor of "Saving lives and staying alive. Humanitarian Security in the Age of Risk Management" (London: Hurst and Co, 2016).</p> </div> <div class="same-author-link"><a href="/index.php/en/michael-neuman" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3249" role="article" about="/index.php/en/marc-le-pape" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-10/photo%20MLP.jpg?itok=IEcezKXq" width="180" height="230" alt="Portrait de Marc Le Pape" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Marc</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Le Pape</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Marc Le Pape has been a researcher at the CNRS&nbsp;and then at the EHESS. He is currently a member of the scientific committee of the CRASH.&nbsp;Formerly with the CNRS, Marc Le Pape is currently a researcher at the l'Ehess (Centre d'études africaines). He has carried out research in Algeria, Côte d'Ivoire and Central Africa. His recent studies have focused on the Great Lakes region in Africa. He has co-directed several publications: <em>Côte d'Ivoire, l'année terrible 1999-2000</em> (2003), <em>Crises extrêmes</em> (2006) et dans le cadre de MSF : <em>Une guerre contre les civils. Réflexions sur les pratiques humanitaires au Congo-Brazzaville, 1998-2000</em> (2001) and&nbsp;<em>Génocide et crimes de masse. L'expérience rwandaise de MSF 1982-1997</em> (2016).&nbsp;</p> </div> <div class="same-author-link"><a href="/index.php/en/marc-le-pape" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3239" role="article" about="/index.php/en/judith-soussan" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-04/DSCF4180.jpg?itok=h3dk1LtW" width="180" height="230" alt="Judith Soussan" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Judith</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Soussan</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Graduated in International relations (Institut d'Etudes Politiques de Paris), Logistics in humanitarian settings (Bioforce-Développement) and Anthropology (University Paris I), Judith Soussan joined MSF in 1999. After missions in Sri Lanka, Ethiopia, Sudan and the Palestinian territories, she worked in Paris, in particular on protection of civilians. Following a few years break from MSF working as a radio reporter, she has come back to Crash in 2015. She contributed to the book "Saving lives and staying alive. Humanitarian Security in the Age of Risk Management" (chapter "Security Issues and Practices in an MSF Mission in the Land of Jihad" - London: Hurst and Co, 2016).</p> </div> <div class="same-author-link"><a href="/index.php/en/judith-soussan" class="button">By the same author</a> </div> </div> </div> </article> </div> <div class="field__item"> <article data-history-node-id="3235" role="article" about="/en/fabrice-weissman" class="node node--type-person node--view-mode-embed"> <div class="node__content"> <div class="group-person-profil"> <div class="group-person-image-profil"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/profile_image/public/2017-04/DSCF4204.jpg?itok=sX0PzbdD" width="180" height="230" alt="Fabrice Weissman" typeof="foaf:Image" class="image-style-profile-image" /> </div> </div> <div class="group-person-content"> <div class="group-person-firstname-lastname"> <div class="field field--name-field-firstname field--type-string field--label-hidden field__item">Fabrice</div> <div class="field field--name-field-lastname field--type-string field--label-hidden field__item">Weissman</div> </div> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>Graduated from the Institut d'Etudes Politiques de Paris, Fabrice Weissman joined MSF in 1995. He spent several years as logistician and head of mission in Sub-Saharian Africa (Sudan, Eritrea, Ethiopia, Liberia, Sierra Leone, Guinea, etc.), Kosovo, Sri Lanka and more recently Syria. He has published several articles and books on humanitarian action, including "In the Shadow of Just Wars. Violence, Politics and Humanitarian Action" (ed., London, Hurst &amp; Co., 2004), "Humanitarian Negotiations Revealed. The MSF Experience" (ed., Oxford University Press, 2011) and "Saving Lives and Staying Alive. Humanitarian Security in the Age of Risk Management" (ed., London, Hurst &amp; Co, 2016).</p> </div> <div class="same-author-link"><a href="/en/fabrice-weissman" class="button">By the same author</a> </div> </div> </div> </article> </div> </div> </div> </details> <div class="clearfix text-formatted field field--name-field-body field--type-text-long field--label-hidden field__item"><p>A selection of books chosen by members of Crash. Happy summer and happy reading !</p> <p>&nbsp;</p> <h3><em>Le Médecin qui voulut être roi</em><br /> Guillaume Lachenal (Seuil, 2017)</h3> <p>A historical investigation as much as a historiographic work, “Le Médecin qui voulut être roi. Sur les traces d’une utopie coloniale” is a fascinating journey in the footsteps of a French colonial doctor, Dr David. Guillaume Lachenal made his mark with his history of Lomidine (Le médicament qui devait sauver l’Afrique, La Découverte, 2014), which resulted in a Crash event / debate with the author in 2015. This book is also about sleeping sickness, but from a broader perspective: what happens when a doctor is granted full administrative powers, for public health purposes, by a colonial power? Looking back at the experiment attempted by Dr Jean Joseph David in a region of Cameroon in the 1930s, Guillaume Lachenal finds the traces it has left on contemporary society and then follows the doctor to Wallis and Futuna, where he had worked several years earlier. His book shares the story of both the investigation and the journey.&nbsp;<a href="http://www.seuil.com/ouvrage/le-medecin-qui-voulut-etre-roi-guillaume-lachenal/9782021142563" target="_blank">Find out more</a><br /> <br /> <span lang="EN-US">English translation forthcoming:&nbsp;<em><span>A Colonial Solution.&nbsp;Dreams and Disasters of a “Wonder” Drug in Africa.</span></em>&nbsp;</span><span>Translation Noemi Tousignant, Johns Hopkins University Press, Baltimore, 2017, sous presse.</span></p> <h3><br /> <em>Passeur</em><br /> Raphaël Krafft (Buchet-Chastel, 2017)</h3> <p>Raphaël Krafft is a radio journalist, known among other things, for cycling through the French regions during electoral campaigns. “Passeur” is the story of a journalist who crosses two borders: the one between France and Italy, which separates Vintimille from Menton, and the other that separates the witness from the actor. Describing his initial involvement as a citizen and journalist with Parisian migrants and his increasing interest in exiles arriving at the gates to Europe, in “Passeur” Raphaël Krafft tells the story of a change in attitude. Having set off to investigate how migrants secretly pass through cols on the border, he finds himself confronting his own conscience and agreeing to help two young Sudanese who are trying to get to France. <a href="http://www.buchetchastel.fr/passeur-raphael-krafft-9782283029572" target="_blank">Find out more</a></p> <h3><br /> <em>Migration: A new Perspective. Building Global Governance</em><br /> Bertrand&nbsp;Badie, Rony&nbsp;Brauman, Emmanuel&nbsp;Decaux, Guillaume&nbsp;Devin, Catherine&nbsp;Whitol de Wenden (La Découverte, 2008)</h3> <p>The authors of this book defend the idea of “good mobility”, countering the current policy of “Fortress Europe”, and suggest an approach to the project of managing global migration. Published in 2008, before the “migrant crisis”, the book invites us to look beyond the opposition between the right to mobility and the right of residence, by organising the phenomenon of migration from the perspective of the common interests of host countries and countries of origin, in particular by opening up the possibility of “pendular” movements. <a href="https://ec.europa.eu/migrant-integration/librarydoc/migration-a-new-perspective-building-global-governance" target="_blank">Find out more</a></p> <h3><br /> <em>De Lesbos à Calais : comment l’Europe fabrique des camps</em><br /> Babels (Le passager clandestin, 2017)</h3> <p>A study of the issue of camps as a new form of emergency accommodation in Europe. This book questions the role of control structures of this kind in Europe, based on field investigations and first-hand accounts.&nbsp;<a href="http://lepassagerclandestin.fr/catalogue/bibliotheque-des-frontieres/de-lesbos-a-calais-comment-leurope-fabrique-des-camps.html" target="_blank">Find out more</a></p> <h3><br /> <em>The truce</em><br /> Primo Levi (The Bodley Head, 1965)&nbsp;</h3> <p>Less well known than “If This is a Man”, his major account of the concentration camps, The Truce is a wonderful little book that varies between gravity and (relative) light-heartedness. It describes the period of Primo Levi’s life between the liberation of Auschwitz and returning to his home in Italy, which took over ten months! Interminable months of waiting for the survivors, who were lugged from camp to camp, in Poland, Russia, Romania and elsewhere. It’s a story full of humour, of an unlikely wander through the heart of a devastated Europe, a daily life of boredom, getting by, friendships and rediscovering life’s small pleasures, against a background of constant uncertainty as to what tomorrow might bring. On the way, Primo Levi sketches some magnificent human portraits of his fellow exiles. <a href="https://www.abebooks.fr/truce-survivors-journey-home-Auschwitz-Levi/7005359957/bd" target="_blank">Find out more</a></p> <h3><br /> <em>State of Rebellion, Violence and Intervention in the Central African Republic</em><br /> Louisa Lombard (Zed Books, 2016)</h3> <p>Louisa Lombard’s book, published in 2016, is an important read against the background of ever-increasing violence in the Central African Republic and given the few high-quality books that deal with the country’s political and social dynamics. As an anthropologist who has worked primarily in the north-eastern border areas, the author has a rare and sophisticated understanding of what drives the political violence that occurs throughout the country. However, her analysis also includes a less than benevolent view of the international initiatives aimed at curbing the violence or even resolving the conflict, and thus launching the great project of building the CAR. <a href="http://press.uchicago.edu/ucp/books/book/distributed/S/bo25073297.html" target="_blank">Find out more</a></p> <h3><br /> <em>Les coupeurs de route. Histoire du banditisme rural et transfrontalier dans le bassin du lac Tchad</em><br /> Issa Saibou (Karthala, 2010)</h3> <p>The consequences of rural crime in the Lake Chad region have sometimes been as dramatic for the people there as war: villages besieged and pillaged, children kidnapped and money extorted from their families, deadly ambushes on the roads, raids on livestock and food supplies, displaced persons trying to flee persecution by criminals, etc. A historian teaching at the University of Maroua, in the far north of Cameroon, Issa Saibou describes in detail the history of the phenomenon and how it fits into the local social and political dynamic.&nbsp;<br /> Using numerous examples and accounts, he demonstrates the porosity that exists between political violence and criminal violence, the key role of the local and national authorities in creating, maintaining and conversely, eliminating criminality, the ambiguous attitude of societies towards “their” criminals (simultaneously feared, loathed and admired by the population), the transformations that have taken place in criminality and its industrialisation in recent times, etc. At the same time, Issa Saibou offers multiple keys to understanding the violence that is currently raging in the Central African Republic, northern Cameroon, Nigeria and Lake Chad, the confrontational and cooperative relationships and the multiple links between the criminals, rebels, state authorities and traditional leaders. <a href="https://www.librairieflammarion.fr/livre/1264337-les-coupeurs-de-route-histoire-du-banditisme-r--issa-saibou-karthala" target="_blank">Find out more</a></p> <h3><br /> <em>L’embuscade de Palestro, Algérie 1956</em><br /> Raphaëlle Branche (Armand Colin, 2010)</h3> <p>How do you tell the story of an ambush? This book is famous for the multiple frameworks it uses to tell the story and explain the ambush, its preparation, consequences, media impact and political objectives for the FLN commando unit Ali Khodja. <a href="http://casbah-editions.com/Catalogue/lembuscade-de-palestro" target="_blank">Find out more</a></p> <h3><br /> <em>Medical Humanitarianism. Ethnographies of practice</em><br /> Sharon Abramowitz et Catherine Panter Brick (University of Pennsylvania Press, 2015)</h3> <p>This joint publication, focusing on anthropological observation of humanitarian medical practices, is one of the most interesting books on the humanitarian sector published in recent years, both in terms of the diversity of situations studied (a dozen) and the density of most of the chapters that make up the book. From camps in Uganda to the medical treatment of asylum seekers in Israel and the questions raised when a humanitarian NGO (MSF, as it happens) leaves Liberia, the authors offer an unparalleled breadth of understanding, which genuinely merits a detailed exploration.&nbsp;<a href="http://www.upenn.edu/pennpress/book/15407.html" target="_blank">Find out more</a></p> <h3><br /> <em>The Origins of AIDS</em><br /> Jacques Pepin (Cambridge University Press, 2011)</h3> <p>(...) are as impenetrable as the ways of the Lord. How do you take a scientific approach to a question that science cannot formally answer? Jacques Pépin, a Canadian specialist in infectious diseases, tackles the subject with gusto, even to the point of moving outside his strict area of expertise. More than the thesis he outlines, the deductive paths he follows offer an opportunity to understand the development of HIV epidemics in their socio-historical contexts. A salutary read, at a time when people are claiming that a biological and social phenomenon that has already caused the early deaths of tens of millions of people is over. May this book help them understand that iatrogenic hygiene practices (in this case, contaminating injections) might have played a significant role in the appearance of large-scale HIV epidemics. It is clearly essential that we remember the damage caused by previous disease-eradication initiatives at a time when states and international organisations are promising that AIDS will have disappeared in a few years. <a href="http://www.cambridge.org/catalogue/catalogue.asp?isbn=9781107006638" target="_blank">Find out more</a></p> <h3><br /> <em>Clavel chez les majors</em><br /> Léon Werth (Viviane Hamy, 2006)</h3> <p>The experience of a soldier and patient in hospitals in the civilian zone during the Great War (the “first”). Léon Werth paints pictures of the sometimes acerbic, sometimes heart-warming stories of doctors, nurses, other patients and the military authorities. <a href="http://www.viviane-hamy.fr/catalogue/collections/litterature-francaise/clavel-chez-les-majors/article/clavel-chez-les-majors?foreign=1161&amp;lang=en" target="_blank">Find out more</a></p> <h3><br /> <em>Mind the Gap: Hierarchies, Health and Human Evolution</em><br /> Richard Wilkinson (Yale University Press, 2002)</h3> <p>In its Millennium Development Goals, the United Nations presents poverty reduction as the aim of any good development policy. This book takes a different view of development, looking not at poverty itself but income inequality. The author, an epidemiologist, starts from the observation that mortality is higher where income inequalities are greatest, rather than where average income is lowest. He offers a fascinating and accessible scientific analysis, based on the biology of stress. <a href="https://www.abebooks.co.uk/servlet/BookDetailsPL?bi=13129682492&amp;cm_sp=seedet-_-plp-_-bdp" target="_blank">Find out more</a></p> <p>&nbsp;</p> </div> <div class="height-computed field field--name-field-related-content field--type-entity-reference field--label-above"> <div class="field__label">Publications associées</div> <div class="field__items"> <div class="field__item"> <article data-history-node-id="3524" role="article" lang="fr" about="/fr/rencontres-debats/le-medicament-qui-devait-sauver-lafrique" class="node node--type-debate node--view-mode-teaser"> <div class="node__content"> <div class="group-teaser-image"> <div class="field field--name-field-teaser-media field--type-entity-reference field--label-hidden field__item"><article class="media media--type-image media--view-mode-teaser"> <div class="field field--name-field-image field--type-image field--label-hidden field__item"> <img src="/sites/default/files/styles/teaser/public/2017-05/guillaume-lachenal-le-me%CC%81dicament-qui-devait-sauver-afrique.jpg?h=3e8895a1&amp;itok=pzQt1Hgu" width="450" height="300" alt="Guillaume Lachenal" title="le médicament qui devait sauver l&#039;Afrique" typeof="foaf:Image" class="image-style-teaser" /> </div> </article> </div> <a href="/en/node/3524" class="main-link"></a> </div> <div class="group-content"> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=3524&amp;2=reading_list" token="0klJF3JgUTFm0Ywuldh1N3D9srsbfq5JfNG3nAjuVwU"></drupal-render-placeholder><div class="bundle-container"><div class="field--name-field-bundle">Débat</div></div><span class="field field--name-title field--type-string field--label-hidden"><h3><a href="/fr/rencontres-debats/le-medicament-qui-devait-sauver-lafrique" hreflang="fr">&quot;Le médicament qui devait sauver l’Afrique&quot;</a></h3> </span> <div class="field field--name-field-debate-start-date field--type-datetime field--label-hidden field__item"><time datetime="2015-02-07T12:30:00Z" class="datetime">07/02/2015 - 13h30</time> </div> <div class="field field--name-field-debate-end-date field--type-datetime field--label-hidden field__item"><time datetime="2015-02-07T18:30:00Z" class="datetime">19h30</time> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/fr/michael-neuman" hreflang="fr">Michaël Neuman</a></div> </div> <div class="node__links"> <ul class="links inline"><li class="node-readmore"><a href="/fr/rencontres-debats/le-medicament-qui-devait-sauver-lafrique" rel="tag" title="&quot;Le médicament qui devait sauver l’Afrique&quot;" hreflang="fr">Read more<span class="visually-hidden"> about &quot;Le médicament qui devait sauver l’Afrique&quot;</span></a></li></ul> </div> </div> </div> </article> </div> </div> </div> <section class="field field--name-comment field--type-comment field--label-above comment-wrapper"> <h2 class="title comment-form__title">Add new comment</h2> <drupal-render-placeholder callback="comment.lazy_builders:renderForm" arguments="0=node&amp;1=4228&amp;2=comment&amp;3=comment" token="0FiUJK5FtHvMaXGHRPEGwsX3jSR5rJyafFADl3nuEWQ"></drupal-render-placeholder> </section> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=4228&amp;2=reading_list" token="RGzn4Rv7122nie1DxJjByJkjlzCHjQG3fa7RgLnSGU4"></drupal-render-placeholder><div class="citation-container"> <div class="field--name-field-citation"> <p> <span>To cite this content :</span> <br> Rony Brauman, Jean-Hervé Bradol, Michaël Neuman, Marc Le Pape, Judith Soussan, Fabrice Weissman, Summer reading, 3 July 2017, URL : <a href="https://msf-crash.org/en/blog/war-and-humanitarianism/summer-reading">https://msf-crash.org/en/blog/war-and-humanitarianism/summer-reading</a> </p> </div> </div> <div class="contribution-container"> <div class="field--name-field-contribution"> <p> <span>If you want to criticize or develop this content,</span> you can find us on twitter or directly on our site. </p> <a href="/en/contribute?to=4228" class="button">Contribute</a> </div> </div> <span class="field field--name-title field--type-string field--label-above">Summer reading</span> Mon, 03 Jul 2017 00:00:00 +0000 Agnes 4228 at https://msf-crash.org Sida : nouvelle pandémie, nouvelles pratiques médicales et politiques https://msf-crash.org/fr/publications/medecine-et-sante-publique/sida-nouvelle-pandemie-nouvelles-pratiques-medicales-et <div class="field field--name-field-publish-date field--type-datetime field--label-inline clearfix"> <div class="field__label">Date de publication</div> <div class="field__item"><time datetime="2011-12-15T12:00:00Z" class="datetime">15/12/2011</time> </div> </div> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/en/user/64" typeof="schema:Person" property="schema:name" datatype="">Corinne-03</span></span> <span class="field field--name-created field--type-created field--label-hidden">Thu, 12/15/2011 - 02:00</span> <div class="field field--name-field-tags field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/tags/aids" hreflang="en">AIDS</a></div> <div class="field__item"><a href="/en/tags/anthropology" hreflang="en">anthropology</a></div> <div class="field__item"><a href="/en/tags/epidemic" hreflang="en">epidemic</a></div> <div class="field__item"><a href="/en/tags/antiretroviral" hreflang="en">antiretroviral</a></div> <div class="field__item"><a href="/fr/tags/pdf" hreflang="fr">PDF</a></div> <div class="field__item"><a href="/fr/tags/epub" hreflang="fr">EPUB</a></div> <div class="field__item"><a href="/fr/tags/vih" hreflang="fr">VIH</a></div> <div class="field__item"><a href="/fr/tags/aids" hreflang="fr">AIDS</a></div> <div class="field__item"><a href="/fr/tags/hiv" hreflang="fr">HIV</a></div> </div> <div class="field field--name-field-authors field--type-entity-reference field--label-hidden field__items"> <div class="field__item"><a href="/en/joan-amondi" hreflang="en">Joan Amondi</a></div> <div class="field__item"><a href="/en/jean-herve-bradol" hreflang="en">Jean-Hervé Bradol</a></div> <div class="field__item"><a href="/en/vanja-kovacic" hreflang="en">Vanja Kovacic</a></div> <div class="field__item"><a href="/en/elisabeth-szumilin" hreflang="en">Elisabeth Szumilin</a></div> </div> <div class="clearfix text-formatted field field--name-field-body field--type-text-long field--label-hidden field__item"><p>It seemed appropriate to assemble these texts now, at a time when the history of our AIDS missions is compelling us to formulate new goals. Until 1996, all we could do was to try to prevent and treat some of the opportunistic infections. Since then, the advent and large-scale distribution of antiretroviral drugs have turned the HIV field upside down, and the new drugs have brought new questions. At what stage of the infection should we start prescribing antiretroviral therapy? What should we do to ensure that every patient who needs treatment can get it, when millions still don't have access? How can we reduce the number of new cases? Can the epidemic be controlled in places where the HIV prevalence is very high?</p> <p>The first text is taken from a book on medical innovation in the specific context of humanitarian situations. It looks at the different attitudes adopted by MSF over the years in response to human immunodeficiency virus (HIV) epidemics, starting in the early 1980s and stopping at the end of the first decade of the 2000s, when millions of patients worldwide began receiving antiretroviral therapy. The second text picks up the thread of that story, but this time at the field project level, in the Homa Bay district of Kenya.</p> <p>The last two texts offer an anthropological perspective on two issues discussed among the Homa Bay project teams: how caregiver team analyses connect the local culture to the spread of the epidemic, and the conditions for patient access to HIV diagnosis and treatment.</p> <p>To this selection we have added a DVD with five films showing the different steps taken to implement preventive and curative treatments in Malawi since the early 2000s. A sixth documentary looks at issues of antiretroviral access in low-income countries from a political and economic perspective.</p> </div> <div class="field field--name-field-chapters field--type-entity-reference field--label-above"> <div class="field__label">Chapitres</div> <div class="field__items"> <div class="field__item"><a href="/en/publications/sida-nouvelle-pandemie-nouvelles-pratiques-medicales-et-politiques/part-1-aids-new" hreflang="en">PART 1 AIDS: A New Pandemic Leading to New Medical and Political Practices</a></div> <div class="field__item"><a href="/en/publications/sida-nouvelle-pandemie-nouvelles-pratiques-medicales-et-politiques/part-2-aids" hreflang="en">PART 2 AIDS: from initiating treatment to fostering patient loyalty</a></div> <div class="field__item"><a href="/en/publications/sida-nouvelle-pandemie-nouvelles-pratiques-medicales-et-politiques/part-3-cultural" hreflang="en">PART 3 Cultural stereotypes and the health seeking behaviour of HIV/AIDS patients in Homa Bay, Kenya</a></div> <div class="field__item"><a href="/en/publications/sida-nouvelle-pandemie-nouvelles-pratiques-medicales-et-politiques/part-4-social" hreflang="en">PART 4 “Social Navigation” and HIV/AIDS</a></div> <div class="field__item"><a href="/en/publications/sida-nouvelle-pandemie-nouvelles-pratiques-medicales-et-politiques/bibliography" hreflang="en">BIBLIOGRAPHY</a></div> </div> </div> <div class="citation-container"> <div class="field--name-field-citation"> <p> <span>To cite this content :</span> <br> Joan Amondi, Jean-Hervé Bradol, Vanja Kovacic, Elisabeth Szumilin, AIDS: A new pandemic leading to new medical and political practices, 15 December 2011, URL : <a href="https://msf-crash.org/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political">https://msf-crash.org/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political</a> </p> </div> </div> <div class="contribution-container"> <div class="field--name-field-contribution"> <p> <span>If you want to criticize or develop this content,</span> you can find us on twitter or directly on our site. </p> <a href="/en/contribute?to=3552" class="button">Contribute</a> </div> </div> <span class="field field--name-title field--type-string field--label-above">AIDS: A new pandemic leading to new medical and political practices</span> Thu, 15 Dec 2011 01:00:00 +0000 Corinne-03 3552 at https://msf-crash.org